191 Boxwood Church Rd (2)`' 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 ules (10 NCAC 10A .1934-.198) / Permit Number
Name V'�� ���` �'��`� ��' Date ~� f�^ a''
Location!`'.«^/'T
Subdivision Name
Lot No
Sec. or Block No.
Lot Size A-! f% ' House Mobile Home _1 Business Speculation _
No. Bedrooms No. Baths — No. in Family - -2_
Garbage Disposal YES ❑ NO Ey,.
Specifications for System -
Auto Dish Washer YES ❑ NO ❑ '` %" }�
Auto Wash Machine YES Eh NO ❑ /Ct,j �.r �� f x.
r✓' / r
Type Water Supply � / _ _—
"This permit Void if sewage system described belov
X411
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 ��•�
1
tcs aG ' 13
J l
t '
i
Certificate of Completion �d /���� (Dae ��' 5
*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.
1. Permit F
2. Address
RECEIVED MAP, 17 198,06
APPLICATION FOR SITE EVALUATION/ IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section
P. 0. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMITHAS
1BEEN ISSUED.
Home Phone
quested By '` �� Business Phone
3. Property Owner if Different than Above aaan2e.4 4 -
Address
4. Permit To: a) Install r/ 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 Homey Business
IndustryOther
b) Number of people C4
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions /4 X 76
Bed Rooms Z Bath Rooms a Den w/Closet
0661114 C4
m 6 A( -
a ltz-,)7&dh ,aC�
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 '2 showers washing machine /
dishwasher 0 sinks
8. a) Type water supply: Public Private Community
b) Has the water supply system been approved? Yes No
9. a) Property Dimensions 2 a 0 C/7 -f -1-
b) Land area designated to building site Q611�
17
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 ' correct to the best of my knowledge.
J(Iola
Date 046x S nature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
I
DCHD (6-82)
i
DAVIE COUNTY HEALTH DEPARTMENT
` Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION /
Name '�"� /7 ,l�i� Date
Address Lot Size CUM cll
FACTORS AREA 1 AREA 9 ARFA 3 AREA A
5
U—UNSUITABLE S—SUITABLE
Recommendations/ Comments: c1
1) Topography/ Landscape Position (:!:r>,� S S
PS PS PS PS
U U U U
2) Soil Texture (12-36 in.) Sandy, S S S S
Loamy, Clayey, (note 2:1 Clay) PS PS
U U
3) Soil Structure (12-36 in.) S S
Clayey Soils PS PS PS PS
U U
4) Soil Depth (inches) S S
dD
PS PS
) Soil Drainage: Internal S S
PS PS
U U
External S S
PS PS
U U
6) Restrictive Horizons
Available Space S S
PS PS PS PS
U U U U
8)
9) Site Classification Other (Specify) S S S S
PS PS PS PS
U U U U
PS -Provisionally Suitable
PS -Provisionally Suitable