690 Cedar Grove Church RdDAVIE COUNTY HEALTH DEPARTMENT.
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION r
*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 1"�,rl�tcy. Date Ln-2U-�j�.+�(2i,16
Location ��t� �tS-r` 6? DA a (;JL"J. Cf_r
Subdivision Name
Lot No
Sec. or Block No.
Lot Size Ac- House Mobile Home `""f Business Speculation
No. Bedrooms 'Z'' No. Baths tea.- No. in Family 7— —
Garbage Disposal YES ❑ NO Q'� Specifications for System: 000�-
Auto Dish Washer YES NO .Q f / .r U
Auto Wash Machine YES U NO Q ZOD X ? / .S/arJ
Type Water Supply .!Ri
*This permit Void if sewage system described below is not installed within 36 months from date of issue.
--£izanrA
Svc7.(/lC s
nv�> K"P
Improvements permit
*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 �f DofNG� �wMiN��'
Certificate of Completion���`�� Date �S
.0
*The signing of this certificate shall indicate that the system describ d 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.
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
ne
Address )e7- ff'x 3 -7
-0-.S AfC, 7-7e- 0 '7
GAr_TnQc APPA I APPA 9
Date 6' /'S
Lot Size-
APPA
ize
ARFA R ARFA A
Topography/ Landscape Position
yySS-��
(PSS
S
S
PS
S
PS
U
U
U
'.) Soil Texture (12-36 in.) Sandy,
Loamy, Clayey, (note 2:1 Clay)
PS
S
S
PS
S
PS
U
U
1) Soil Structure (12-36 in.)
'C
S
PS
S
PS
Clayey Soils
PS
U
U
U
i) Soil Depth (inches)
S,
(!ff>
S
S
S
PS
PS
PS
U
U
U
U
i) Soil Drainage: Internal(T)c
S
S
PS
PS
PS
U
U
U
U
External
6
S
S
PS
PS
PS
PS
U
U
U
U
i) Restrictive Horizons
') Available Space
S
PS
S.
PS
S
PS
S
PS
U
U
U
U
1) Other (Specify)
S
PS
S
PS
S
PS
S
PS
U
U
U
U
!) Site Classification
U—UNSUITABLE
Recommendations/ Comments:
S—SUITABLE /' PS—Provisionally
Described by TitleDate
SITE DIAGRAM -`
o
1
DCHD (6-82)
APPLICATION FOR SITE EVALUATION/ IMPROVEMENTS PERMIT
U� Davie County Health Department
U Environmental Health Section
R 0. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
1. Permit Requested By
2. Address
Home Phone�9/��
Business Phone 9/2,,,) 0'74222
3. Property Owner if Different than Above
Address 2 Q11/�%�? �O v7
4. Permit To: a) Installer 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/ Business
IndustryOther
b) Number of people .7
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions /"/ X_ &
Bed Rooms 2 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
lavatory _
dishwasher
urinals garbage disposal
showers / washing machine
sinks
8. a) Type water supply: Public ✓ Private Community—
b)
ommunity b) Has the water supply system been approved? Yes No
9. a) Property Dimensions dk,02r2—f')
Gtp'XQ
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? 12,8
What type?
This is to certify that the information is correct to the best of my knowledge.
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)
STATEMENT
_ DAVIE COUNTY HEALTH DEPARTMENT
ENVIRONMENTAL HEALTH SECTION
210 HOSPITAL STREET
P. 0. BOX 665
MOCKSVILLE, NORTH CAROLINA 27028
(704) 634-5985
DATE 61 - 2-0 - '9
F �3fi/cE y
dc�k 37
W -S /c 27 0 ?
L
DETACH AND MAIL WITH YOUR CHECK.
c
YOUR CANCELLED CHECK IS YOUR RECEIPT.
BALANCE DUE -