P4879 Duke Whitaker RdImprovements 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:
Installed by
V
Certificate of Completion �`+/ Date 91�i��
*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.
` 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_: Date
a
is
Location .: �..r . �.���..__�_r_s-, ;�.,j.., z.,, .j t_j
Subdivision Name Lot`No. Sec. or Block No.
p
Lot Size l i House Mobile Home — Business Speculation
No. Bedrooms —No. Baths _ No. in Family _
Garbage Disposal YES ❑ NO
Specifications for System:
Auto Dish Washer YES ❑ NO p
/ ,r;
Auto Wash Machine YES ®' NO ❑
�, (t,� - l+
Type Water Supply
*This permit Void if sewage system described below is not installed within 36 months from date of issue.
o
_J-0
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:
Installed by
V
Certificate of Completion �`+/ Date 91�i��
*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.
f 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 PERMIT HAS BEEN ISSUED.
1. Permit Requested By ,u/9r rQ / t I) cj r L YL
2. Address 13S 1) 'L w
3. Property Owner if Different than Above
Address
4. Permit To: a) Install Iter Repair
b) Privy Conventional Other Type
Ground Absorption
Home Phone �IFZ- %S(? I
Business Phone _Z3 " i es -p
c) Sub -Division Sec. Lot No.
5. System used to serve what type facility: House Mobile Home k--Susiness
Industry Other
b) Number of people
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions /ZL Q y t/s^
Bed Rooms off-- Bath RoomsDen 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 �rivate Co munity
b) Has the water supply system been approved? Yes7No
9. a) Property Dimensions / a r -P 6
b) Land area designated to building site
c) Sewage Disposal Contractor L) Il&fd &
10. Do you anticipate any additions or expansions of th� faciity this sewage system is intended to serve?
What type?
This is to certify that the information is correct to the best of my knowledge.
7 A)
Date Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
Ooke �(i� � ��l�� r o2 � � s o,- Kj5 h 1
OCHD (6.82) �b, Z y. r� e
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name J_�,�� a 1-S�e Date
Address Lot Size
FACTORS AREA 1 AREA 2 AREA 3 AREA A
1) Topography/ Landscape Position
SS
PS
S
PS
U
U
U
U
2) Soil Texture (12-36 in.) Sandy,
Loamy, Clayey, (note 2:1 Clay)
S
PS
S
PS
U
U
U
U
3) Soil Structure (12-36 in.)
Clayey Soils
S
S
S
PS
S
PS
U
U
U
I) Soil Depth (inches)
S
CvrPS
S
S
PS
U
U
U
i) Soil Drainage: Internal
A
S
PS
S
PS
U
U
U
U
External
S
4ks
S
PS
S
PS
U
U
U
i) Restrictive Horizons
Available Space
S
cf�C7
S
U
S
PS
U
S
PS
U
I) Other (Specify)
S
PS
U
S
PS
U
S
PS
U
S
PS
U
1) Site Classification
U—UNSUITABLE
Recommendations/Comments:
S—SUITABLE PS Provisionally Suitable
Described by \ �' Title Date
SITE DIAGRAM
DCMD (6-82)
Name—
Address
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section.
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Date
Lot Size
FACTORS AREA 1 AREA 9 AREA 3 AREA A
1) Topography/ Landscape Position
9)
S
S
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
PS
PS
U
U
U
U
3) Soil Structure (12-36 in.)
S
S
S
S
Clayey Soils
PS
PS
PS
PS
U
U
U
U
1) Soil Depth (inches)
S
S
S
S
PS
PS
PS
PS
U
U
U
U
i) Soil Drainage: Internal
S
S
S
S
PS
PS
PS
PS
U
U
U
U
External
S
S
S
S
PS
PS
PS
PS
U
U
U
U
i) Restrictive Horizons
Available Space
S
S
S
S
PS
PS
PS
PS
U
U
U
U
1) Other (Specify)
S
S
S
S
PS
PS
PS
PS
U
U
U
U
Site Classification
U—UNSUITABLE
Recommendations/Comments:
S -SUITABLE PS—Provisionally Suitable
Described by Title Date
SITE DIAGRAM
VCHD (6.82) Air