223 Maplewood Ln (2) DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
`Note: Issued i Compliance with G.S. of North Carolina Chapter 130—Article 13c.
Permit Number
Name Date
Location
/ ,���.• ��'- � ,� lit� -� � � _ / /s j/r%.-'; j�:f / y�I�L__t� "" - a.�1��'�'
Subdivision Name Lot No. Sec. or Block No.
Lot Size =F' %' House Mobile Home _ Business !-_-''" Speculation
No. Bedrooms No. Baths No. in Family
Garbage Dispoc al YES ❑ NO ❑ Specifications for System:
Auto Dish Washer YES ❑ NO fl /
Auto Wash Mac i ine YES ❑ NO ❑
Type Water Su ply _
*This permit Vo d if sewage system described below is not 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 :00-1:30 P.M. on day of completion. Telephone Number: 704-634-5985.
Final Installatio Diagram: System Installed
Certificate of Completion.- -1K"L�"� Date//
*The signing of this certificate shall indicate that the system descril3ed above has been installed in compliance with
the standards et forth in the above regulation, but shall in NO way be taken as a guarantee that the system will function
satisfactorily f r any given period of time.
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. 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 Positioner S S S
PS 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 U
3) Soil Structure (12-36 in.) S S S S
Clayey Soils PS PS PS
U U U U
4) Soil Depth (inche ) S S S S
U PS PS PS
U U U
5) Soil Drainage: Int rnal S S S S
PS PS PS
U U U U
Ex ernal lz� S S S
PS PS PS PS
U U U U
6) Restrictive Horiz ns
7) Available Space 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—Provision uitable
Recommendations/Comments:
Described by Title Date
SITE DIAGRAM
1
DCHD(6-82)
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section
R 0. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone
1. Permit Requested By /' Business Phone
2. Address
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 usiness
IndustryOther
b) Number of people Z
6. a) If house or mobile home, state size of home and number of rooms.
Hous Dimensions
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 w I ter supply: Public Private �&mmunity
b) Has the water supply system been approved? Yes No
9. a) Property Dimensions y �
b) Land aea 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.
Date Owner Signature
WNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions toproperty:
DCHD(6-82)