141 Foster Dairy Rd (2) 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 � 7
Location �SJ �r1 ST jc; i� %UJT�',� �n�,
s1
Subdivision Name Lot No. Sec. or Block No.
Lot Size House Mobile Home —� '� Business Speculation
No. Bedrooms �' No. Baths No. in Family t _
Garbage Disposal YES ❑ NO
Specifications for System:/000
Auto Dish Washer YES W NO ❑
Auto Wash Machine YES NO ❑ i\ V?00 X 3 X
Type Water Supply ,d 4)/47
*This permit Void if sewage system de� ribe-d elow is not inAaIA within 36 months from date of issue.
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Improvements permit bye`'r
*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: 704-6134-5985.
Final Installation Diagram: System Installed byL�e�v%Z�fL
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Certificate of Completion'
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 "5-
Environmental
SEnvironmental Health Section
!9 - P. O. Box 665
Mocksville, N.C. 27028
V - 'T/'� SOIL/SITE EVALUATION
Name IbMA,..� � � Date .-= Z' �!
Address 4 P%rc(w m..j Lot Size
kbvA,rc.-- NL
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position 0 SP S S
PS' S PS PS
U, U U U
2) Soil Texture (12-36 in.) Sandy, S S S S
Loamy, Clayey, (note 2:1 Clay) PS PS
U U U
3) Soil Structure (12-36 in.) S S S S
Clayey Soils PS PS PS
9 U U
4) Soil Depth (inches) S SPS 0 PS PS
U U U
5) Soil Drainage: Internal S S S S
PS � PS PS
\u U U
External S S )
PS PS PS
U U U
6) Restrictive Horizons
7) Available Space S S S
PS P 8 PS PS
U U U U
8) Other (Specify) S S S
PS PS PS
U U U U
9) Site Classification PS
U—UNSUITABLE S—SUITABLE PS—Provisionally Suitab
Recommendations/Comments:
Lcst..r �-r� !�T! e3E �'EfJ !/� ��✓El2.S!rn. ,�s+) T-N'TE/�'EPOa-�-.
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Described by sy' Title ��' « Date r�
SITE DIAGRAM \�
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DCHD(6-82)
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department Zj
Environmental Health Section ��
P. O. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED
Home Phone
1. Permit Requested By ni� Business Phone
2. Address
3. Property Owner if Different than Above `Ss
Address I
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 &) l
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions �-
Bed Rooms a• Bath Rooms Den w/Closet
b) If Business, Industry or Other, State: Number of persons served AM
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 1�5
8. a) Type water supply: Public Private Community
b) Has the water supply system been approved? Yes] No,
9. a) Property Dimensions 1515 )� a 3 D
b) Land area designated to building site
c) Sewage Disposal Contractor C.-e-�1
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.
Date Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
04 A" `
"0101�
DCHD(6-82)