1137 Baileys Chapel Rd (2)-r�1-.:. fir:.... • h
DAVIE ' 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 ��'G`: �i Date `�f%:'/ R gip` . ^97.
J
Location
Subdivision Name
Lot No. Sec. or Block No.
Lot Size.' House Mobile Home Business Speculation
No. Bedrooms `T_ 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.
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:
i` 01,x'
k
System Installed by-> �' l.`I f17ZI-,
Certificate of Completio'� Date6
cr ed above has been installed
*The signing of this certificate shall indicate that the system desalled 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
R O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name Date
Address Lot Size—'ea-424��
RAt'rnQe AREA I APPA 9 ARFA 3 APPA A
) Topography/ Landscape Position
2)
3)
4)
5)
«)
8)
9)
S�–�
S
S
TP;S/
PS
PS
U
U
U
Soil Texture (12-36 in.) Sandy,
Loamy, Clayey, (note 2:1 Clay)
S
S
S
PS
S
PS
U
U
Soil Structure (12-36 in.)
Clayey Soils
S
PS
S
PS
U
U
U
Soil Depth (inches)
S
S
PS
PS
PS
U
U
U
Soil Drainage: Internal
S
S
S
PS
S
PS'
U
U
External
S
S
S
PS
PS
PS
PS
U
U
U
U
Restrictive Horizons
Available Space
C ,
S
S
PS
PS
U
U
U
U
Other (Specify)
S
PS
S
PS
S
PS
S
PS
U
U
U
U
Site Classification
U—UNSUITABLE
Recommendations/Comments:
Described by
SITE DIAGRAM
DCHD (6-82)
S—SUITABLE PS—Provisionally Suitable
Title Dat
APPLICATION FOR SITE EVALUATION/ IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section
P. O. Box 665 RECEIVED ��� 9 ;A
Mocksville, N.C. 27028 086
/NCONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone 491- (n °2 P Y
1. Permit Requested By 7q.( Ch a'7 ,�( C 4'Y)7 ZLQ/ _Business Phone 22 a - 3 70
2. Address L, /q(, A P 'Ad
3. Property Owner if Different than Above
Address
4. Permit To: a) Install ✓ Alter Repair
b) Privy Conventional Other Type
Ground Absorption
c) Sub -Division Sec. Lot No.
5. System used to serve what type facility: Housed Mobile Home Business
IndustryOther
b) Number of people 4 �
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions as x 6'0
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 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) Property Dimensions / 0 ry 1,
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 cor t to tree bestt of my knowledge.
rf - Cl - R (I
Date Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
qU
�eQ 6t c' l A� bi a_& ) ctt-h 1,00
DCHD (6-82)