P3870 Will Boone Rd '
DAVIE 'COUNTY.'HEALTH. DEPARTMENT t.
IMPROVEMENTS PERMIT AND CERTIFICATE .OF .COMPLETION
*NQTE: Issued in Compliance with G.S.-of North Carolina Chapter,130 Article) 13c.
Sewage Treatment and Dis oral Rules 10.NCAC 10A .1934-:1968): . y Permlt ;Numb®F
Name 9 �p (
Date 5� /7 ; 8s� 8II�O r
Location
.Subdivision Name 1 Lot No.. Sec. or Block No.` '
Lot. Size, , House i` — Mobile Home _ Business' Speculation
` No. Bedrooms No. Baths_ No. in,Family: z, '
Garbage Disposal: ` YES fl NO
Specifications for System: 10(3o C 71
Auto Dish Washer . . YES NO
Auto Wash Machine YES NO fl T
Type Water Supply
*This permit Void if sewage:'system-described below is not installed-within 36(months from date of issue.
f; SU, L
p .
•+ �• � 1. �'` i ,T ', i� T � .
0' Improvements permit by
ate.
j. ---
*Contact a representative of the Davie.County'Health Department for final inspection of this system between '8:307
9:30 A.M. or 1:00-1:30 P.M:- on day of completion, .Telephone;Number: 704-634-5985:
. Final Installation Diagram: u ;; System Installed by'
' fir' �. �I r .I)� r - 1{ -' i. •
Certificate of Completion Date' J
_.
The signing of this-certificate'shall indicate that the system described above has.been�Jnstalled'.in compliance with-
the standards set forth in fhe'above-reg ulation, but shall in NO way betaken as a guarantee that the system will function
satisfactorily for any given; period of time: -
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
R O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
NameDate
ohm 5a. llm-A-N 17
7
Address 212 Lot Size Z ov �114�c�
270
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position 4!!� ��.�'� S S
PS PS PS PS
U U U U
2) Soil Texture (12-36 in.) Sandy, S S S S
Loamy, Clayey, (note 2:1 Clay) qn5--> cj�— PS PS
U U U U
3) Soil Structure (12-36 in.) S S S S
Clayey Soils � <::� PS PS
U U U U
4) Soil Depth (inches) S S S
PS PS
U U U
5) Soil Drainage: Internal S S S
PS PS
U U U
External ^ S S
PS PS
U U U U
6) Restrictive Horizons
7) Available Space S S S
PS
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=Proro )v'sionaliy Suitab e
Recommendations/Comments:
3
Described by 4- TitleDate q
,SITE DIAGRAM
L
l t# `
F•
DCHD(6-82)
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section
R 0. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone
1. Permit Req u sted By 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_l.�-Mobile Home Business
IndustryOther
b) Number of people Z-
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions X-91-r-V N
Bed Rooms R -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? Yes4eN0 r e.'Y
9. a) Property Dimensions
b) Land area designated to building site .y4 e.)
c) Sewage Disposal Contractor 7!f,,r ./ate 41711 4-t_
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 co ect to the best of my knowledge.
I s f, 41
....�-
Date 40wrfer Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
Alert}"� s' "
�s
� f
)
4
..........
DCHD(6-82)