178 W Bolin 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
Sewage Treatment and Disposal Rules (10 NCAC 10A .1934-.1968) Permit Number
Name , '' ;: ' , ' / s Date X22 r is',
Location ✓�� 1 /"�} <% ' — � ,%',-,i 1:�' /,-% t°�— ,�,+',
Subdivision Name Lot No. Sec. or Block No.
Lot Size `'-'' House Mobile Home Business Speculation
No. Bedrooms t No. Baths _� No. in Family _
Garbage Disposal YES ❑ NO Er' Specifications for Syst m:
Auto Dish Washer YES NO ❑
Auto Wash Machine YES NO ❑ <� } f ,;
Type Water SuPPIY
--�--
"This permit Void if sewage system described below 's ndt 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 1:00-1:30 P.M. on day of completion. Telephone Number: 704-634-5985.
Final Installation Diagram: �'' System Installed b
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.
APPLICATION FOR SITE EVALUAT-ION/IMPROVEMENTS PERMIT P A' S�IYA
r* Davie County Health Department '
Environmental Health Section
4. P 0. Box 665
Mocksville, V.C. 27023
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS-BEEN l8&Urz:),_
Nome atone
1. Permit Requested 'By �- Business Phone
2.`Address ;
3. Property Owner if Different than Above
4. Permit To:a) Install. Alter Repair
b) Privy�ConventionalJl_Other Type.._
Ground Absorplion
c)Sub-Division Sec ._Lot No.
5. System used to serve what type fa ility: House_Mobile H Mme � 3usine�s-
IndustryOther_
b) Number of people
6. a) If house or mobile home,state size of home and number of rooms.
House Dimensions Q
Bed Rooms_Bath Rooms_._.,Den w/Closet _
b) If Business, Industry or Other, State: Number of person> served
What type business, etc.
Estimate amount of waste dally (2-:1 hours).___
7. Number anq type of water-using fixtures:
commAes— 2 urinals_- garbage 41sposai _
lavatory showers :xjashing Machine—
dishwasber sinks
8. a)Type water supply: Public F'rivate_.A,`�_ Community
b) Has the water supply system been approved? Yes--No--
9. a) Property Dimensions—, -
b) Land area designated to building sit:) �--- _
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 ect to the b st of my knowledge.
�/L
Date owner Signature .440
IS) R SPONSIBLE FOR COMPUANC WITH ALL STATE AND LOCA LAVVS
OWNER L� SOLELY E
Allow 5 clays for processing
Directions to property: d
CCH (6.82)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name Date ,
Address Lot Size 4a:%
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position S S S S
PS 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 PS
U U U
3) Soil Structure (12-36 in.) S S S
Clayey Soils PS PS PS
U U U U
4) Soil Depth (inches) S S S
X�' PS PS PS
U U U U
5) Soil Drainage: Internal S S S
PS PS PS
U U U U
External S S S S
j PS PS PS
U U U
6) Restrictive Horizons
7) Available Space S S- S S
PS PS PS
U U U
8) Other (Specify) S S S
, PS PS PS
�
U U U
9) Site Classification 1
151
U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable
Recommendations/Comments:
Described by -J`��J� / Title Date
SITE DIAGRAM
DCHD(6-82)