212 Pine Forest Ln DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTE: Issued in Compliance with G.S. of North Carolina Chapter 130.Article 13c
Sewage Treatment and Disposal Rules (10 NCAC 10A .1934-.1968) Permit Number
Name t,)0-4( n /1 i2rr r" c. 4 2 '- �1 r'.,A;
DAVIE COUNTY HEALTH DEPARTMENT
cL
Environmental Health Section ? 7 11'
7
P, 0. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name PNA-ttD 4g^syuyj&-- Date /0–
Address
0–Address �40(0 &,0A1Z4DA-t£ Lot Size �y�
4w6-- / d, '070z/
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position /0 S S
PS PS PS PS
U U U U
2) Soil Texture (12-36 in.) Sandy, S S S
Loamy, Clayey, (note 2:1 Clay) P PS PS
U U U
3) Soil Structure (12-36 in.) S S S
Clayey Soils PS PS
U U
4) Soil Depth (inches) � S S
(PrS) PS PS
U
U � U U
5) Soil Drainage: Internal S S S S
An PS PS
U U
External S S S
PS PS
U U
6) Restrictive Horizons
7) Available Space S S. S S
PS PS PS PS
U U U U
8) Other (Specify) S S S S
PS PS PS PS
U U U U
9) Site Classification
U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable
Recommendations/Comments:
Described by Title <'�""f� '� z Date
SITE DIAGRAM
r
DCHD(6-82)
2:At 4£SDAy
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMI
Davie County Health Department /
Environmental Health Section ptll"
r. R O. Box 665 C(./I•� Gp-isPL iG
Mocksville, N.C. 27028 �crZ -7Zy'7
7
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone-N I Q ` '�?)-,)Ott)
1. Permit Requested By Business Phone
2. Address
3. Property Owner if Different than Above
Address
4.' Permit To: a) Install-1ZAlter Repair
b) Privy Conventional Other Type
Ground Absorption
c) Sub-Division Sec. Lot No.
5. System used to serve what type facility: House Mobile Home Business
IndustryOther
b) Number of people
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions143 1
_
Bed Roomss3 Bath Rooms_—Den w/Closet
b) If Business, Industry or Other, State: Number of persons served
What type business, etc.
Estimate amount of waste daily (24 hours)
7. Number and type of water-using fixtures:
commodes a urinals garbage disposal
lavatoryshowers washing machine
dishwasher ( sinks 5
8. a) Type water supply: Public Private X/ Community
b) Has the water supply system been approved?Yes No-Z
9. a) Property Dimensions \ -A 5
b) Land area designated to building site
c) Sewage Disposal Contractor l
10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve? No
What type?
This is to certify that the information 7ort to the best of my kn ledge.
Date Owner Signatur
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
fro �Wt. (DL� WtSf T �auc� Qcj 9d, r!Q+_ Ca1t 1aA'S
Z&0L'tA_, at'v�) -r L. 6-r' 64Dt_ R8.
� Paw, 6 CT A8.
cr , L. (, 6j_*-y'� +0
Lt' 0-t rmo_Aaydfru�
'kms,-5 �• fir : c�n-w . T 12 , a-Aa.
rtryG. l O 0 �d y• o� �.
lhivL 'vs o, LoLti_) o,&qA atcu_ncl o.- �'l q'_VCR_
WiLtt b.c WIU UL. Wu- k CkL - is Imo. . JL_, w j_c)
01so 6- 4- 4aik'a 'i" .
T1 o� -7 0?4-7 U0_4 C d Of rL0_4 - 6p-W
DCHD(6-82)