270-277 Tall Timbers Dr DAVIE COUNTY HEALTH DEPARTMENT
--' r IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
"NGTE: Issued in Compliance with G.S. of North Carolina Chapter 130 Article 13c
Sewage Treatment and Disposal Rules, 10 NCAC 1.OA .1934-.1968) Permit Number
Name ��1R:: r�G' "� = - r.�� Date
c • _ .� s G s,n..
Location
Subdivision Name Lot No. Sec. or Block No.
Lot Size ._S- House Mobile Home —1 Business _— Speculation
No. Bedrooms No. Baths No. in Family 2
Garbage Disposal YES ❑ NO ❑ Specifications for S Y stem:
Auto Dish Washer YES ❑ NO ❑ >� r
Auto Wash Machine YES ❑ NO ❑ U
Type Water Supply
*This permit Void if sewage system described below is not installed within ontFr9 from date of issue.
a
Improvements permit by — (
r ^ _
`Contact a representative of the Davie County Health Depar nt for fin alrf' spection of this system between 8:30-
9:30 A.M. or 1:00-1:30 P.M. on day of completion. T\phon Number: 04-634-5985.
Final Installation Diagram: ystem nstall d by
__j
Certificate of Completion / ' Date v
'The signing of this certificate shall indicate that the system described above has been installed in compliance with
the standards set forth in the above regulation, but shall in NO way be taken as a guarantee that the system will function
satisfactorily for any given period of time.
` APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
• Davie County Health Department
Environmental Health Section
4 R O. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone
1. Permit Requested By Business Phone
2. Address uc -
3. Property Owner if Different than Above ///-- �Lv
Address
4. Permit To: a) Install Iter Repair
b) Privy_—ConventionalOther Type
Ground Absorption
c) Sub-Division '" Sec. - Lot No.
5. System used to serve what type facility: House Mobile Home Business
Industry Other
b) Number of people_ 13
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions
Bed Rooms 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 urinals garbage disposal
lavatory showers washing machine
dishwasher sinks
8. a) Type water supply: Public Private Community
b) Has the water supply system been approved? Yes No_C
9. a) Property Dimensions
b) Land area designated to building site
c) Sewage Disposal Contractor
10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve?
What type? —
This is to certify that the information is correct to the best of my knowledge.
Date Owner Signatu ' --
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property: �U. � rj,
(SR /3/3)
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- DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
R O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
me Date
ddress Lot Size
FACTORS AREA 1 AREA 2 AREA 3 . AREA 4
1) Topography/Landscape Position S �� S
PS �PS� PS
U �J�' U
2) Soil Texture (12-36 in.) Sandy, S S S S
Loamy, Clayey, (note 2:1 Clay) PS ® PS
U' ZJ U
3) Soil Structure (12-36 in.) S S
Clayey Soils PS PS PS
U
4) Soil Depth (inches) S S
PSP� 5% 'C P PS
U
5) Soil Drainage: Internal S S S
PS P PS
U U
External S S S S
PS PS PS PS
U U U U
6) Restrictive Horizons r,�---
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
i
Recommendations/Comments:
Described by Title Date
SITE DIAGRAM
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