413 Will Boone Rd (2) w
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t.t�. DAVIE COUNTY HEALTH DEPARTMENT 14IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTE: Issued in Compliance with G.S. of North Carolina Chapter 130 Article 13c
Sewage.Treatmennt and Disposal Rules (10 NCAC 10A .1934-.1968) Permit Number
Name .�!o"I'1 2
N2 - "•
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Location 5-4 45' - �'., r}'����1i?lj�✓ ����- �%�' 7��:.. �r;�.� � ,%.,� ��
. ,F'f V� ,S'�,.-/.,('rr" ✓�` .,<7.F',,C .//✓'f/<.� � �f'/'=�/ r,.r� �F,l,.c�+°/' � �`,�/:;-^� ..v-��E''/ —
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Subdivision Name Lot No. Sec. or Block No.
Lot Size_ Z22, ' House Mobile Home Business Speculation
No. Bedrooms •- "' No. Baths No. in Family_ f
Garbage Disposal YES ❑ NO Specifications for System:
Auto Dish Washer YES NO ❑ 1,� 'r�;
Auto Wash Machine YES NO E]
Type Water Supply _
*This permit Void if sewage system described below is not installed within-a6-months from date of issue.
Improvements permit by _ZZ-4Z N
*Contact a representative of the Davie County Health Department forfinal inspection of this system between 8:30-
9:30 A.M. or 1:00-1:30 P.M. on day of completion. Telephone Num er: 704-634-5985.
Final Installation Diagram: System Ins ailed by
CP
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Certificate of Completiony Date �� - L
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
./�Vim'.{ r ta... iJ, •.
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
'NOSE: IssLed in.Compliance with G.S. of North Carolina Chapter 130 Article 13c
Sewage Treatment and Disposal Rules (10 NCAC 10A .1934=.1968) Permit Number
Named ;/Date -- -�'�/ '9 N2 5738
Location <r/S �: i /7i�T✓ r/f' d( �' .is> �//�( �I�,G't% f i d
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Subdivision Name - Lot No. Sec. or Block No.
Lot Size /'1//l House Mobile Home Business Speculation
No. Bedrooms �"� _ No. Baths - No. in Family---?
Garbage Disposal YES ❑ NO f.]--"
Specifications for Syslem:
Auto Dish Washer YES NO ❑
Auto Wash Machine YES [� NO ❑ �
Type Water Supply _ 6 .z00 , X/
6 o " ()A&
'This permit Void if sewage system described below is not installed within-0&months from date of issue.
f
Improvements permit by
*Contact a representative of the Davie County HealthDepartment 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 Ins ailed by
0
O Q, .
11 \
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Certificate of CompletionDate
*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. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name— Date I,
Address Lot Size—
FACTORS
ize FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position S S
(ip _._ _.. u-
2) Soil Texture (12-36 in.) Sandy, S � S
Loamy, Clayey, (note 2:1 Clay) ( rte' PS
9P
�0 (�
3) Soil Structure (12-36 in.)
Clayey Soils
4) Soil Depth (inches) S S
U U
5) Soil Drainage: Internal S
PS
UU
External
S PS PS PS
U U U U
6) Restrictive Horizons
7) Available Space S
U
8) Other (Specify) S S S S
PS PS PS PS
U U U U
9) Site Classification rl,
U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable
Recommendations/Comments:
Described by �l j Title Date
SITE DIAGRAM
DCMD(6-82)
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APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section
R O. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone -�� /I��
1. Permit Requested By �� i Business Phone
2. Address U
-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
Industry Other
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`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
9. a) Property Dimensions AL c
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?
e
This is to certify that the information is correct to the best of my knowledge.
Date Owne ign t re
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
j *NOTE: Improvements Permits shall be valid for a period of 5
years from date issued. Improvements Permits are subject
( to revocation, if site plans or the intended use change. ;!
Effective October 1, 1989.
DCHD(6-62)