1294 Eatons Church RdDAVIE COUNTY HEALTH DEPARTMENT -
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION ; i3
*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.
- p Name Date ` /� �- a �'", 3315
- Location / _ l" iy,<" �;i�.�^ /�i'i �:=r.l" ;✓J —
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 p-*, Specifications for System:
Auto Dish Washer YES NO ❑ ,,G . i-��� �, ,r �,�;
Auto Wash Machine YES T 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
i
*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 bye n, Ct 0,
J
N
K4
1
Certificate of Completion `�1 Date 21 r6
'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
P. O. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone 1 "! 8 r 3 g 7
1. Permit Requested By 5U4 r Ce M U Y-ra N Business Phone
2. Address ���� �o� a�� n1n��csu)�1e c—
3. Property Owner if Different than Above
Address
4. Permit To: a) Install Alter Repair
b) Privy Conventional Other Type
Ground Absorption
c) Sub-DivisionSec. Lot No.
5. System used to serve what type facility: House Mobile Home Business—
Indust
usinessIndustry Other
b) Number of people 14
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions a6l
Bed Rooms— 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
lavatory, I showers )
dishwasher I Public
�
garbage disposal
washing machine I
8. a) Type water supply: Public Private Community—
b)
ommunityb) Has the water supply system been approved? Yes --"—/No
9. a) Property DimensionsAt
b) Land area designated to building site V-^ _
c) Sewage Disposal Contractor
10. Do you anticipate any additions or expansions of the acilitythis sewage system is intended to serve?
What type?
This is to certify that the information is correct to the best of my knowledge.
5 f 3DA3 .
Date Owner Si ature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property: I / UWa
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DCHD (6.82) / �' _ • � _ _'
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DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
R O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name Date
Address Lot Size '
1ZAr.TC1RC ARFA 1 ARFA 9 ARFA 3 AREA A
Topography/ Landscape Positioner
2)
#)
5)
�)
8)
9)
�
S
PS
S
PS
U
U
U
U
Soil Texture (12-36 in.) Sandy,
S
S
S
Loamy, Clayey, (note 2:1 Clay)
:./
PS
PS
U
U
U
U
1) Soil Structure (12-36 in.)
Clayey Soils
S
S
-_5)
S
PS
S
PS
U
U
U
U
Soil Depth (inches)
S
S
S
PS
S
PS
–�
U
U
U
Soil Drainage: Internal
S
S
PS
S
PS
U
U
External
S
S
S
PS
PS
PS
PS
U
U
U
U
Restrictive Horizons
Available Space
S
S.
S
PS
U
U
S
PS
U
Other (Specify)
S
PS
S
PS
S
PS
S
PS
U
U
U
U
Site Classification
U—UNSUITABLE
Recommendations/Comments:
S—SUITABLE PS—Provisionally Suitable
Described by Title �Date
SITE DIAGRAM
DCHD (6-82)