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DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
NOTE: Issued 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 4! , 'f / �.:, Date 6 4 7
Location 1 ;�_1r s ,� �, - .,.:> ✓. �.a,. /�;', , _
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 Specifications for System:
Auto Dish Washer YES NO ❑
Auto Wash Machine YES NO ❑ f
Type Water Supply \ __
"This permit Void if sewage system desbGibed below is not installed within 36 months from date of issue.
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ImprovemenWermi
Contact a representative of the Davie County Health Department r fin in ection of his system between 8:30-
9:30 A.M. or 1:00-1:30 P.M. on day of completion. Telephone umb . 70 -634-5985.
Final Installation Diagram: Syste1st ed by r �
Certificate of Completion Bate
"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.
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APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section
P. 0. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone O- 3 3
1. Permit Requested By J C- Business Phone 8902 7/O&7
2. Address-V -7 d oxZf/1 Wd vi
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
J/ IndustryOther
b) Number'of people `T
6. a)if house or mobile home, state size of home and number of rooms.
House Dimensions ;a X. 3
Bed Rooms 3 Bath Rooms 0- Den w/Closed
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 /D X 3 0 D =142&�JIJ,
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? 9Zt2
What type?
This is to certify that the information Is correct to the best of my knowledge.
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Date wner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
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CH0(6-82)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
R 0. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name Date
Address Lot*Size
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position S S S
PS PS
2) Soil Texture (12-36 in.) Sandy, S S S
Loamy, Clayey, (note 2:1 Clay) C P PS PS
U U U
3) Soil Structure (12-36 in.) S S S S
Clayey Soils S PS PS
"U U U
4) Soil Depth (inches) S S S S
PSS PS PS PS
U U U
5) Soil Drainage: Internal S S S S
pg -,-PS� -. PS PS
U U U
External S S S, S
PS PS PS PS
U , U U U
6) Restrictive Horizons
7) Available Space S S ;} S S
PS: PS 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—SUITABLE PS—Provisionally Suitable
Recommendations/Comments:
Described by Title Date
SITE DIAGRAM
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