296 Vogler Rd (2) rC i
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 � r=-, Date
Location
Subdivision Name Lot No. Sec. or Block No.
Lot Size P1 /�~ House I_.- Mobile Home — Business -- Speculation
No. Bedrooms fJ No. Baths No. in Family,Z
Garbage Disposal YES NO p Specifications for System:
Auto Dish Washer YES NO
Auto Wash Machine YES NO -p
Type Water Supply
`This permit Void,if sewage system described below is not installed within 36 months from date of issue.
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 _Zz Date
'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.
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. 0. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION /
Name__ Janine Voglar Date JM
Address P_C1 Rnx•476 Adunnce, Nr Lot Size ,&(
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position S S S
PS d;) PS PS
U U U
2) Soil Texture (12-36 in.) Sandy, S S S
Loamy, Clayey, (note 2:1 Clay) �8) Cl PS PS
U U
3) Soil Structure (12-36 in.) $ S S
Clayey Soils PS PS
`U U U U
4) Soil Depth (inches) S S
P3 ~�U PS PS
U U U
5) Soil Drainage: Internal S S
PS PS
U
U U U
External S S
PS PS
U U U U
6) Restrictive Horizons
7) Available Space CJ' 1.—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—Provisional Suitable
Recommendations/Comments:
Described by `'� Title .!/y �1� Dat
SITE DIAGRAM
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DCHD(5-82)
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APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section
P. 0. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone
1. Permit Regr By 1✓-e �/ Business Phone
2. Address
3. Property Owner if Different than Above
Address
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
IndustryOther
b) Number of people
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions
Bed Rooms Bath Rooms en 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
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.
RZ"2a:&� — 4-M. e
Date - Owner Signature if
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property: �
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DCHD(6-82)
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