P4494 WoodleeDAVIE COUNTY HEALTH DEPARTMENT
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 % i r, a , - ✓ r . r!
Subdivision Name
Lot No. Sec. or Block No.
Lot Size
House
Mobile Home Business -- Speculation
No. Bedrooms- -7
— No. Baths
r-1
amily
No. in Family-
Garbage
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.
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 `'�`�\�� -
\ u
(7--
0
Certificate of Completion ) C�`� 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
Davie County Health Department
Environmental Health Section pp
P. O. Box 665 ` iECE1 VFDSEP
Mocksville, N.C. 27028 7 f9$6
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone-
1.
hone 1. Permit Requested By pct u l _ S tic �T� Business Phone 9 — '1
2. Address —& c 1,22 e3
3. Property Owner if Different than Above
Address
4. Permit To: a) Install-IZAlter Repair
b) Privy Convention al—_LZOthe r Type
Ground Absorption
c) Sub -Division Sec. Lot No.
5. System used to serve what type facility: House Mobile Home Bs
IndustryOther
b) Number of people 3
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions
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 Z urinals garbage disposal
lavatory 2 showers 2 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
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? -16,' n
What type?
This is to certify that the information is correct to the best of my knowledge.
Date Ow er Sign Ore
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
-
J�
r
WE
DCHD (6-82)
Address
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. 0. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Date —
Lot Size
FACTORS AREA 1 AREA 2 AREA 3 ARFA 4
) Topography/ Landscape Position
2)
3)
4)
5)
N)
8)
9)
S
S
S
(VS
PS
PS
PS
U
U
U
Soil Texture (12-36 in.) Sandy,
S
S
S
Loamy, Clayey, (note 2:1 Clay)
PS
PS
PS
PS
U
U
U
Soil Structure (12-36 in.)
S
S
S
Clayey Soils
PS
PS
PS
U
U
U
Soil Depth (inches)
S
S
S
pS
PS
PS
PS
U
U
U
Soil Drainage: Internal
S
S
S
P
PS
PS
PS
U
U
U
External
S
S
S
S
PS
PS
PS
( �U
U
U
U
Restrictive Horizons
Available Space
S
S
S
S
PS
PS
PS
U
U
U
U
Other (Specify)
S
S
S
S
PS
PS
PS
PS
U
U
U
U
Site Classification
flL ,
U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable
Recommendations/ Comments:
Described by Title Date
SITE DIAGRAM
DCHD (6-82(