113 Haywood Dr Lot 9 ,,y W .•' -lf 1�2C� `),C 1)z,1�c G�'-J�7�ra t,f f' DAVIE COUNTY HEALTH DEPARTMENT 113YWM�
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 �,
Location ✓ /-r,� / f ! - t
Subdivision Name �� %' f Lot No. Sec. or Block No. ZZ
Lot Size l' House Mobile Home _ Business Speculation
No. Bedrooms - No. Baths --1� No. in Family -
Garbage Disposal YES p NO El- Specifications for System:
Auto Dish Washer YES Q NO p , , ; %'
Auto Wash Machine YES Q NO {]
Type Water Supply
`This permit Void if sewage system described below is not installed within 16_months from date of issue.
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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 by ��� �A 5
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F.
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.
s
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name_ Z;5;oJ'fDate
Address Lot Size
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position ,. S S
Pel PS PS
`-� U U
2) Soil Texture (12-36 in.) Sandy, S S
Loamy, Clayey, (note 2:1 Clay) PS PS
`lT U U
3) Soil Structure (12-36 in.) S S S S
Clayey Soils IDU PS
U U
4) Soil Depth (inches) S S S
T S PS PS
U U U U
5) Soil Drainage: Internal ��-, S S
PS PS
U �� U U
External S S
PS PS PS
U U
6) Restrictive Horizons
7) Available Space S S S
g PS PS PS
U U U U
8) Other (Specify) S S S S
PS PS PS PS
QU U U . U
9) Site Classification
U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable
Recommendations/Comments: at 'y
Described by Title �� v Dateo/'�'/-
SITE DIAGRAM
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DCHD(6-82)
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APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Departmentd'
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 Reques ed By + Business Phone E
2. Address o o 6 r-6- ' DD
3. Property O ner if Different than Above J6jl..v
Address Wkv W /' n )
r ,1
4. Permit To: a) Install Alter Repair,_
b) Privy Conventionaly/ Other Type
Grou d Absorptio
c) Sub-Division EW ec Lot No. �j
5. System used to serve what type facility: House-*,'—' Mobile Home Business_ 1V/r/V tit
IndustryOther
b) Number of people
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions /X/X 6�Q�
Bed Rooms -3 Bath Rooms � '� Den w/Close
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 3 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) ProRerty Dimensions
b) Land area designated to building ite + -
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 i correct t the best of my knowledge.
a 11
Dae caner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE H ALL STATE AND LOCAL LaS
Allow 5 days for processing
Directions to property:
Ale 60 Y/�d1vit) V-4 y
DCHD(6-82)
DAVIE COUNTY HEALTH DEPARTMENT
4o79
Environmental Health Section
R O. Box 665
Mocksville, N.C. 27028 Y'
SOIL/SITE EVALUATION
Name Z* - '4—W=P2A0wA1 Date Z -1W
Address �'s/ 7�� Lot Size
271,02-
FACTORS
71,0ZFACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position S S S S
® PS PS
U U U U
2) Soil Texture (12-36 in.) Sandy, SS S
Loamy, Clayey, (note 2:1 Clay) PS PS
U U U U
3) Soil Structure (12-36 in.) S S S S
Clayey Soils EEP � PS PS
U U U U
4) Soil Depth (inches) ® CMD S S
�S �P" US� l
S PS
5) Soil Drainage: Internal S S S
PS PS PS
U U U U
External S S S S
<�M PS PS
U U U U
6) Restrictive Horizons a�
14
7) Available Space 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—SUITABLE S—Provisionally Suitable
Recommendations/Comments: .56x-/
Described by- Q•rn�+� Title 1 � - Date
SITE DIAGRAM lAR�k1h
173. ►3'
r �
V
L
.71/•
DCHD(6-82)