P3976 Burton RdDAVIE 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 Dis osal Rules (10 NCAC 10A .1934-.1968) Permit Number
Name ^ /nr ,,. �,!G'�rf/ ��f' ., Date ,.,`' /lN, 21 3 97 6
.. r'✓jG'r' rte'",// !�' i'''c'• / /%' I .a -e',. r- ��.,�..,r_..
Location Y
Subdivision Name Lot No. - Sec. or Block No.
Lot Size House Mobile Home _ Business __ Speculation
No. Bedrooms �— 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: System Installed by
Z
Certificate of Completion 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
R 0. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
.�. Home Phone Yyf-,;'?SN
1. Permit Re que ter] By d Aj V ltlfl 6 Business Phone
2. Address ,
3. PropertyOw/�er if Different than Above
Address Z�gl
4. Permit To: a) Install-ZAlter Repair
b) Privy Conventional'/ Other Type
Ground Absorption
c) Sub -Division Sec. Lot No.
5. System used to serve what type facility: House Mobile HomeBusiness
,/� IndustryOther
b) Number of people `r'
6. a) If house or mobile home, state sizeofhome and number of rooms.
House Dimensions
Bed Rooms Bath Rooms Den w/Close aN "
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:
commode 112
urinals garbage disposal
lavatory C,L showers r, 2 washing machine
dishwasher 1 sinks R
8. a) Type water supply: Public Private V-`00 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 is to certify that the information is correct to the best of my knowledge.
----
//w—
/Date er Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
7, Ile
go
9.0
' L ted P�"
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DCHD (6.82) /
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. 0. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION 1�
Name ��/-` %-� Date
Address Lot Size AZW60
CAf%Tf1QQ AREA i ARFA 9 AREA 3 ARFA A
N
2)
3)
5)
6)
8)
Topography/ Landscape Position S S S S
d PS PS PS
U U U U
Soil Texture (12-36 in.) Sandy, S S S
Loamy, Clayey, (note 2:1 Clay) PS PS PS
U U U U
Soil Structure (12-36 in.) S S S
Clayey Soils PS PS PS PS
U U U
#) Soil Depth (inches) S S S S
PS PS PS
U U U U
Soil Drainage: Internal S S S S
PS PS PS
U U U U
External S S S S
PS PS PS
U U U
Restrictive Horizons
)'Available Space �S S. S S
crJ PS PS PS
tT, U U U
Other (Specify) S S S S
PS PS PS PS
U U U U
9) Site Classification
U—UNSUITABLE
Recommendations/ Comments:
Described by _
SITE DIAGRAM
DCHD (6-82)
S—SUITABLE PS—Provisionally Suitable
Title
Date
U—UNSUITABLE
Recommendations/ Comments:
Described by _
SITE DIAGRAM
DCHD (6-82)
S—SUITABLE PS—Provisionally Suitable
Title
Date