367 Oakland Avenue Lot 128DAVIE COUNTY' HEALTH DEPARTMENT'
.,.i. .
.� 'IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
,.-"NOTE: Issued in Compliahee with-G.S. of North Carolina Chapter 130 Article 1.3c
Sewa e Treatment'and�Disposal Rules (10 NCAC 10A .1934-.1968) Permit Number'
Date.
Name��r/� 32
Location
Subdivision Name fs - Lot No.
Lot Size f' House Mobile ,Home ! Business
No. Bedrooms No. Baths �� No. in Family
I' ' `' YES NO
Sec. or Block No.
Speculation
al age Isposa fl Ca Specifications for System:
Auto Dish Washer YES NO'
Auto, Wash Machine ';> .YES g NO
APPLICATION FOR SITE EVALUATION/ IMPROVEMENTS PERMIT C':"
Davie County Health Department �.
Environmental Health Section,.z
P. O. Box 665
Mocksville, N.C. 27028 j
c'
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.��
C 4�9
Home Phone �ti
1. Permit Requested By ���' l �'roe�n Business Phone2.Address < -� - Z_1 "4
3. Property Owner if Different than Above
Address
4. Permit To: a) Installer Alter Repair
b) Privy Conventional Other Type
Ground Absorption
c) Sub-Divisionoal–O Sec. Lot No.
5. System used to serve what type facility. Mobile Homes
IndustryOther
b) Number of people
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions
i
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
lavatory
dishwasher
urinal
showers
sinks
garbage disposal
washing machine
8. a) Type water supply: Public Private Community
b) Has the water supply system been approved? Yes�No
9. a) Property Dimensions I/ LIQ �� �—
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? Alf-,
What type?
This is to certify that the information is correct to the best of m knowledge.
�z 1/s 6 ? Date Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
DCHD (6-82)
0
.0
Name Grady L. McClamrock
Address
F
F
E
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
R O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Date
Lot Size �7'
FACTORS AREA 1 AREA 2 AREA 3 ARFA 4
Topography/ Landscape Position
PS
�S
�
S
PS
U
S
PS
U
'.) Soil Texture (12-36 in.) Sandy,
Loamy, Clayey, (note 2:1 Clay)
PS
U
S
PS
U
S
PS,
U
1) Soil Structure (12-36 in.)
Clayey Soils
U
S
(2697
`U
S
PS
U
S
PS
U
1) Soil Depth (inches)
S
S
U
S
PS
U
S
PS
U
�) Soil Drainage: Internal
�S
:PSS
S
PS
U
S
PS
U
External
U
S
PS
U
S
PS
U
�) Restrictive Horizons
Available Space
S'S
S
PS
U
U
S
PS
U
1) Other (Specify)
S
PS
U
S
PS
U
S
PS
U
S
PS
U
1) Site Classification
/�,�S -1F
hoc
U—UNSUITABLE
Recommendations/ Comments:
S—SUITABLE "PS—Provisionally Suitable
Described by Title
SITE DIAGRAM
DCHD (6-82)
Date