619 NC Hwy 801S Lot 29DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTE: Issued in Compliance with G.S. of North Carolina Chapter 130 Article 13c
Sewage Treatme ; and Disposal Rules (10 NCAC 10A .1934-.1968 Permit Number
Name.��!� /�:�y�� � /� Date N2
0 2 77
Location ,ter%/'t:lf'/r''F-'
Subdivision Name 1-f�xc/i`1''r� 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 ❑
Type Water Supply
*This permit Void if sewage system described below is not installed within 36 months from date of issue.
,._...._.._...-.. _.4--
Vc�'f 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 \x\ •�
R1
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 EVALUATION/ IMPROVEMENTS PERMIT
r 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.
m ; C Home Phone l 919- 69 Z/O
1. Permit Re ested By �I d0. �'c r fe w Business Phone . ?6c, -`-// 95
2. AP'otUn no
3. Property Owner if Different than Above
Addrass
4. Permit To: a) Install Alter Repair
b) Privy Conventional Other Type
Ground Absorption
c) Sub -Division Se Lot No.
5. System used to serve what type facility: House - Mobile Home Business
Industry Other
b) Number of people a,
6. a� If house or mobile home, state size of home and number of rooms.
House Dimensions 'Z a` �- °$f� `�' K, I P
Bed Rooms 3 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 a urinals garbage disposal
lavatory 3 showers a washing machine
dishwasher sinks
8. a) Type water supply: Public ✓ Private Community
b) Has the water supply system been approved? Yesy No
9. a) Property Dimensions Ck_ hukdI; o moo x 200
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?
What type?
This is to certify that the information is correct to the best of my knowledge.
e-8-89 <:7�' a S . C0_0t'e--
Date Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property: Ft
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I5�
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DCHD (6-82)
Name—
Address
FAr.TnRR
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section.
P. 0. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION l�
Date
Lot Size 11W
AREA 3 ARFA 4
ARFA 1 ARFA 2
1) Topography/ Landscape Position
S
S
PS
S
PS
U
U
?) Soil Texture (12-36 in.) Sandy,
Loamy, Clayey, (note 2:1 Clay)
S^
�
U
PSS,
S
PS
U
S
PS
U
1) Soil Structure (12-36 in.)
Clayey Soils
PS
S
PS
S
PS
U
U
U
Soil Depth (inches)
pS
S
PS
S
PS
S
PS
U
U
) Soil Drainage: Internal
S
PS'
S
PS
S
PS
U
U
External
S
S
PS
S
PS
7
U
U
U
Restrictive Horizons
Available Space
PS
U
d�
PS
U
S
PS
U
S
PS
U
�) Other (Specify)
S
PS
U
S
PS
U
S
PS
U
S
PS
U
) Site Classification
P S
5-
U—UNSUITABLE
Recommendations/Comments:
S—SUITABLE PS—Provisionally Suitable
Described by Title
SITE DIAGRAM
DCHD (6-82)
Date