638 Richie RdDAVIE COUNTY HEALTH DEPARTMENT
c' 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,/�l'� ���` Date r` , . %� 4987
Location�7ij�i
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 J2– Specifications for System:
Auto Dish Washer YES NO ❑ y``
Auto Wash Machine YES g 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 /1/c.�f�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 by
,�, I
Certificate of ompletio � Date v __
�v
'The signing of this certificate shall indicate that the system described above As 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.
.may,/� n/ Home Phone
1. Permit Requested By /�/'4PtvA5'l,4 `—o " Business Phone UZ ) 39�-a 99`?�
2. Address R 5 61 >21ecC' rYI &e, d 2d2 S
3. Property Owner if Different than Above-S'/fi/h
Arlrlraca
4. Permit To; a) Install
_�<Alter Repair
b) Privy Conventional Other Type
Ground Absorption
c) Sub -Division Sec. Lot N
5. System used to serve what type facility: House Mobile HomeBusiness
Industry. Other
b) Number of people CZ �71 LrJO
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions X ('�20
Bed Rooms Bath Rooms._ Den w/Closet—L—
b) If Business, Industry or Other, State: Number of persons served Jy
What type business, etc.
Estimate amount of waste daily (24 hours)
7. Number and type of water -using fixtures:
commodes a 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—t,>,,e /
9. a) Property Dimensions 1A ei?E' /D o X � ''? 4
b) Land area designated to,building site 1�2 x (;;�o
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.
C TerS
Date 7 Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
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a104a l e -A 710 A-)
Ra4�-�G,� ��►s�P ��%�s� Oma,
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DCHD (6-82)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Box 665
Mocksville,N.C. 27028
SOIL/SITE EVALUATION
Name Date
Address Lot Size
FAC.TCIRR ARFA 1 ARFA 9 ARFA 3 AREA A
9
Topography/ Landscape Position
9)
S
S
S
S
PS
PS
PS
U
U
U
!) Soil Texture (12-36 in.) Sandy,
S
S
S
S
Loamy, Clayey, (note 2:1 Clay)
�
PS
PS
PS
U
U
U
U
1) Soil Structure (12-36 in.)
�
S
S
S
Clayey Soils
(�S�
PS
PS
PS
`�j�j
U
U
U
1) Soil Depth (inches)
S
S
S
S
PS
PS
PS
U
U
U
�) Soil Drainage: Internal
S
S
S
PS
PS
PS
PS
U
U
U
External
S
S
S
PS
PS
PS
PS
U
U
U
1) Restrictive Horizons
Available Space
®
S
S
S
PS
PS
PS
PS
U
U
U
U
1) Other (Specify)
S
S
S
S
Pg`
PS
PS
PS
U
U
U
U
Site Classification
U' S
U—UNSUITABLE S—SUITABLE �S—Provisionally Suitable
Recommendations/Comments: /
Described by �G / Title
SITE DIAGRAM
4
DCHD (6-82)
Date