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DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTE: 'Issubo ih Compliance with G.S, of North Carolina Chapter 1;30 Article 13c
Sewage Treatment and Disposal Rules (10 NCAC 10A .19314-.1968) Permit Number
�;
Names e c., �1. �`, '� �. Date
Location
Subdivision Name Lot No Sec. or Block No.
,Lot Size A House Mobile Home _ Ii : Business' Speculation
No. Bedrooms No. Baths No. in Family-
i'1
Garbage Disposal YES -p NO Specifications for System:.�
Auto Dish Washer YES p NO ; /ice, ,r, t
Auto Wash Machine YES F� NO p , `'
Type Water Supply � f�x_
*Phis permit Void if sewage system described below is not installed- within 36 months from date of issue. -
,.
• lid
• +I
ImpFovements permit by
*Contact a representative of the Davie County Health Department fo•� final inspection of this system between 8:30-
9:30 A.M. 0 100-1:30 P.M. on day of completion: Telephone Number: 704-634-5985.
Final Installati laiegram: System Installed by 1 7—
Oo !l
�1
F n{rP!
1
1,
e -
Certificate of Completion Date r u
*The signing of -this certificate shall indicate that the system described above hasibeen installed in compliance with
the standards set forth in the above regulation, but shall in NO way betaken as a guarantee that the system will function
satisfactorily for any given period of time.
i
1;, - ,•' Off- �� I V
APPLICATION FOR SITE EVALUATION/ IMPROVEMENTS PERMIT
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. c /
Home Phone 9 9 �✓^ 3 7s
1. Permit Requested By '� Business Phone O J 7
2. Address 2 %!
3. Property Owner if Different than Above
Address
4. Permit To: a) Inst'att—J 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 Homme Business
IndustryOther
b) Number of people 2-
6.
6. a} If house or mobile home, state size of home and number of rooms.
House Dimensions * Z(')
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 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
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 ' tat\he informatio
e.
uate �lwner-signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property: )5N 5�s
�zS zs'
-------------------------
DCHD (6-82)
a
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section.
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name m�� 6x, Date
Address CI A TIN— Lot Size
FACTORS AREA 1 ) ARECJ ARLA 3l ARFA
I) Topography/ Landscape Position
SS j
C
PS
U
U
U
?) Soil Texture (12-36 in.) Sandy,
Loamy, Clayey, (note 2:1 Clay)
S
3) Soil Structure (12-36 in.)
CIe Soils
S
S
U
U
—35
y Soil Depth (inches)�_.
5_�
S
S
S'
PS
U
U
U
PS
U
i) Soil Drainage: Internal
pS
PS
U
PS
PS
External
U
U
U
i) Restrictive Horizons
Available Space
SS
PS
S
P
S
U
U
U
U
1) Other (Specify)
S
PS
S
PS
S
PS
S
PS
i) Site Classification
S
J
U—UNSUITABLE S BLE PS---F7rov sionally Suitable
Recommendations/Comments:
Described by - Title Date
SITE DIAGRAM
VCHD (6.82)