1496 Peoples Creek Rd (2) "" - DAVIE COUNTY HEALTH DEPARTMENTS b
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 Date /'� Z ��� j� 311,
'65 ur.• r' 5
Location ISP) e? fi� � �Ov 1—� 0 V'i t"z_oF c x C re f i,- �l�r.J hi4-"Jhr-e ;
t —
Subdivision Name ___ Lot No. Sec, or Block No.
Lot Size fy A`— House `�� Mobile Home _/ / Business Speculation
No. Bedrooms _ No. Baths No. in Family
Garbage'Disposal YES NO ❑ Specifications for System:/00 _.��. 4•'�-
Auto Dish Washer YES NO ❑
Auto Wash Machine YES NO '❑ y
Type Water Supply _
*This permit Void if sewage system described below is not installed within 36 months from date of issu.�-�
/�5
ImpA ements permit by,?%%�.���
*Contact a representative f th Qavie ounty Heal epartment for final inspection of this system between 8:30-
9:30 A.M. or 1:00-1:30 \on Zday of com�vI61 Telephone Number: 704-634-5985.
Final Installation Diagram: System Installed by ' CGl�i)►ri�
l
!P15
;� S%
Certificate of Completion I / �'' Date J
*The signing of-1his certificate shall indicate that the system describe 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.
ry
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name TA-v1!> Porr5 Date 11 ,
Address /4�k /k%e2y 'eD• Lot Size ov
Io-S MC, 27/07
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position S S
PS PS
U U U U
2) Soil Texture (12-36 in.) Sandy, S S S S
Loamy, Clayey, (note 2:1 Clay) V q PS PS
U U
3) Soil Structure (12-36 in.) S S S S
Clayey Soils $ PS PS
U U
4) Soil Depth (inches) S S S
P� PS PS PS
U U U U
5) Soil Drainage: Internal �S-,� S S
(p,�J PS PS
U U U
External S S S S
�pg PS PS PS
U U U U
6) Restrictive Horizons
7) Available SpaceIS
S S S
S PS PS
U U U U
8) Other (Specify) S S S S
PS PS PS PS
U U U U
9) Site Classification
U—UNSUITABLE S—SUITABLEPS—Provisionally Suitab
Recommendations/Comments:
Described by SQA Title sem' �'�^' Date
SITE DIAGRAM
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DCHD(6-82)
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APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone C//':�' 78 8—Vc)l9
1. Permit Requested By V DBusiness Phone
2. Address lDD '6P'AV 27/ 07
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
IndustryOther
Business—
b) Number of people
6. a) If house or mobile home, state1size of home and number of rooms.
House Dimensions .3c)
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 Z urinals garbage disposal /
lavatory 3 showers 7- washing machine
dishwasher f sinks
8. a) Type water supply: Public Private Community
b) Has the water supply system been approved? Yes No '
9. a) Property Dimensions d
b) Land area designated to building site
c) Sewage Disposal Contractor
10. Do you anticipate �y additions or expansions of the facility this sewage system is intended to serve?
What type? A)
This is to certify that the information is correct to the best of my k I dge.
Date Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
U w/ ,
DCHD(6-82)