150 Dots Ln DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
`Note: Issued in Compliance with G.S. of North Carolina Chapter 130—Article 13c.
Permit Number
Namel2f l.'« ,.,--- -J�' Date2 �, Z ,�-
;.' 4"
Location
Subdivision N IIm,,,��e Lot No. Sec. or Block No.
[A
Lot Size / �- — House Mobile Home Business Speculation
No. Bedrooms z-- No. Baths No. in Family 2-
Garbage Disposal YES ❑ NO E❑ Specifications for System:/Doo
Auto Dish Was er YES p NO ❑
Auto Wash Machine YES E:] NO ❑ 7_00
Type Water Supply ^JI `'`- _ " / �' �)El C"oAjC'("i G
*This permit V id 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 t 0 P.M. on day of completion. Telephone Number: 704-634-5985.
Final Installati Diagram: System Installed by�� ��`�
�f c) -
Certificate of Completion . -e-c Date /
*The signing o 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 �2► �v Cf{F.�n, Date ?
Address T. �X 3-7Lot Size AL
kv6o-z-r- %/1 ns c 2-7°2-,r
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position S S S
PS PS PS PS
U U U U
2) Soil Texture (12- 6 in.) Sandy, S S S
Loamy, Clayey, (note 2:1 Clay) PS PS PS
— - U U U
3) Soil Structure (12-36 in.) S S S S
Clayey Soils ® PS PS PS
U U U U
4) Soil Depth (inches) S S S
PS PS PS
U U U U
5) Soil Drainage: In ernal S S S
PS PS PS PS
U U U U
E ternal S S S
QS PS PS PS
U U U U
6) Restrictive Horiz ns
7) Available Space S- S S
PS PS PS PS
U U U U
8) Other (Specify) 0 pS PS PS
U U U U
9) Site Classificatio
U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable ,t/ Z
Recommendations Comments:
Described by Title-5,4�,Ji7AZ/'dN Date
SITE DIAGRAM
i
y
"a
DCHD(6-82)
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section
R O. Box 665
Mocksville, N.C. 27028
ONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone
1. Permit Re sted By"Z�&-c-+ - Ts� �C_k043 )Yl Business Phone 1 6 �� �► ��
2. Address - �- 1oX `7
3. Property Olwner if Different than Above
Address
4. Permit To: a) Install Alter Repair�
b) Privy Conventional ZOther Type
Ground Absorption
c) Sub-Division Sec. Lot No
5. System us ad to serve what type facility: House Mobile Home---L/Business—
Industry—
ome BusinessIndustryOther
b) Number of people -�
6. a) If house or mobile home,,s�ttatee size of home and number of rooms.
Hous Dimensions 2 o�x
Bed ooms a Bath Rooms Den wieloset )
b) If Busin ss, Industry or Other, State: Number of persons served
What type business, etc.
Estimate amount of waste daily (24 hours)
7. Number aid type of water-using fixtures:
comr iodes urinals garbage disposal d
lavat ry 1 showers washing machine
dish asher sinks
8. a) Type w ter supply: Public Private Community
b) Has th water supply system been approved?Yes No
9. a) Prope Dimensions l 19 G 2E
b) Land a ea designated to building site EY9 e 01
c) Sewag Disposal Contractor
10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve? N 6
What typ (?
This is to certify that the information is correct to the best of my knowledge.
�121g :;�
Date Owner Signature
WNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to roperty:
—fylcU�L-01
Ise
DCHD(6-82)