138 Taylor Rd !" r I� � -_ ._.- . ..-V` ..v--`i�-.ww .. -_ � - - • - - 19.• ��'Y. 5// ../, . ,gyp V
DAVIE COUNTY HEALTH DEPARTMENT .�.
IMPROVEMENTS PERMIT. AND CERTIFICATE OF COMPLETION
*NOTE: Issued in.Compliance with IG.S,':of. North Carolina Chapter 130 .Article 13c'.
Sewage'Treatment. and Disposal-Rules (10 NCAC 10A :1934-.1968) Permit Number
Name J�h �'r� �� �' Date ' - a6 24
Location it i I hJ -!- e ` � .j 't� c
'Subdivision Name' Lot No Sec. or Block No.`
Lot Size House Z Mobile Home _ Business , Speculation
No. Bedrooms No: Baths_ _ No. in Family
Garbage Disposal .'YES ❑ NO`p Specifications:for System:
Auto Dish Washer, . YES E] NO f 0 t _
Auto Wash Machine YES U' NO ❑
0,� a • k � 4
Type Water Supply
`This permit Voidjf sewage;;system described below is not installed within 36 months from date of issue.
i' Improvements permit by
"Contact a representative of the Davie County Health Department for final inspection of this system between 8:30-
9:30 A.M. or 1:00-1:30 P.M. on day of completion. Telephone Number: 704-634-5985.
Final Installation Diagram: System Installed by
�Certificate'of Completion" Date
The signing of this certificate shallsfndicate 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+; '
_ - A
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section
P o. Box 665 RECEIVED
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED. �f
Home Phone
1. Permit Requested By tlG Z G Business Phone,7sa-'3 3 6
2. Address o b TE O 8 CE C'- a2 Qd
3. Property Owner if Different than Above
Address '5'�;M C
4. Permit To: a) Install Alter 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
—
b)
Industry—Other
b) Number of people 7,"v �
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions �0 X .91 9 y (Y0
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 approve)?Ye No
9. a) Property Dimensions
b) Land area designated to building site
c) Sewage Disposal Contractor S 47L
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 corrg t to the best of my �01
edge.
47
Date Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
C�Al
Allow 5 days for processing
Directions to property: _
14
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DCHD(6-82)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name p a�4-� O��Q Date
Address Lot Size e �
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position S S
P P PS PS
U U U
2) Soil Texture (12-36 in.) Sandy, S S
Loamy, Clayey, (note 2:1 Clay) S PS PS
U U U U
3) Soil Structure (12-36 in.) S S
Clayey Soils PS PS
U U
4) Soil Depth (inches) S S
P lP9 PS PS
Tl U U
5) Soil Drainage: Internal S S
PS PS
U U U U
External S S S S
PS PS PS PS
U U U U
6) Restrictive Horizons
7) Available Space S S
P PS PS
U U U U
8) Other (Specify) S S S S
PS PS PS PS
U U U U
9) Site Classification S
U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable
Recommendations/Comments:
Described by � `�" Title Date O
SITE DIAGRAM
DCHD(6-82)