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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 Treatme and Disposal Rules 410 NCAC 10A .1934-.1968) Permit Number
Name .f� ,'�-;� t'4-<��e Date //i/ 4� <—`" 1? ^-t2
• AYI
Location ,, ._. i/ )6 /r" �✓. r� tea_
Subdivision Name Lot No. Sec. or Block No.
Lot Size House Mobile Home.—&— Business Speculation
No. Bedrooms `% No. Baths — No. in Family
Garbage Disposal YES ❑ NO p' Specifications for S stem:
Auto Dish Washer YES + NO ❑
Auto Wash Machine YES NO ❑ �lTir _
Type Water Supply �'''�:
*This permit Void if 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 Depar rnen for final inspection of this system between 8:30
9:30 A.M. or 1:00-1:30 P.M. on day of completion. Tele on Number: 704-634-5985. .
Final Installation Diagram: Sys em Installed by, eZIMAeZI�Z
Certificate of Completion Date
*The signing of this certificate shall indicate that the system describ d above has been installed incompliance 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 /
Name4��L
Date
Address Lot Size Z202
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position 5 S
S PS �iPS�
U Z�!"
2) Soil Texture (12-36 in.) Sandy, S S
Loamy, Clayey, (note 2:1 Clay) PS (PSS
U
3) Soil Structure (12-36 in.) S S S
Clayey Soils PS
U lT
4) Soil Depth (inches) S S S S
PS PS our)
U
5) Soil Drainage: Internal S S
• PS PS
���tttJJJ
. External � S S
U U
6) Restrictive Horizons
7) Available Space S S.
PS S
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—Provisionally Suitable
Recommendations/Comments:
Described by Title ,,� Date
SITE DIAGRAM
A2
.4L
P
DCHD(6-82)
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department 'n,�
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED. per/
Home Phone�T
1. Permit Req s ed By Business Phone
2. Address -
3. Property Owner if Different than Above
Address
4. Permit To: a) Install Alter Repair
b) Privy Convention al�/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. �'f p,�j�`e �py,� e f'I R$/YL
House Dimensions b �u Y C jcc S e d ye ` —
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 U
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.
D e ner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property: -r
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DCHD(6-82)