158 Edge Way"~° VAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS,—PERMIT.,AND CERTIFICATE OF COMPLETION
ti `a .V
*NOTE: Issued in Compliance with G.S. of North Caro Iina-Chao r 130 Article 13c
Sewage Treatment and Disposal Rules (10 NCAC 10A .1934-.1968) Permit Number
Name_ .a ,,,��, t�C> "�- Date - `l
Location
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 p/ NO ❑
Auto Dish Washer YES ❑ NO p'
Auto Wash Machine YES [.]' NO ❑
Type Water Supply '\,, (� •- �
r�
Specifications for System:
`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.
, l',,
Final Installation Diagram: System Installed by
Certificate of Completion Date
t
'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.
� I 40
^' APPLICATION FOR SITE EVALUATION/ IMPROVEMENTS PE MI �d PQM
\� Davie County Health Department
Environmental Health Section
P. 0. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUD
Home Phone cX 0 .a 34 r7
1. Permit Reque ted By 7�2L�c
nni-f 4t/ wh/��,c Business Phone
2. Address r , 7 &X 3G/ -q 191dc1<ru1//c A(C
3. Property Owner if Different than Above
Address 1A % do
4. Permit To: a) Install ✓Alter Repair
b) Privy-t!:L Conventional Other Type
Ground Absorption
c) Sub -Division Sec. Lot No.
5. System used to serve what type facility: House Mobile Home ✓ Business
Industry Other
b) Number of people
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions /C/ D!( 70
Bed Rooms Z Bath Rooms Z 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 garbage disposal t
lavatory showers Z washing machine
dishwasher sinks 3
8. a) Type water supply: Public Private Community
b) Has the water supply system been approved? Yes No 1Z
9. a) Property Dimensions �) •'S A`f-Gos
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? CS
What type? hOIJ'/c
This is to certify that the information is correct to the best of my knowledge.
yz/ ze �ffl � , &.X -1 -kc,
Date 0 ner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property: C1AA'sAont 9O 5A+\. c(N-\.A
��wa y �-o Me- leo -< dc4,� you ccc� �o C— �t{y c`Ro� root
Ql1 the 1-. Q �o �h� e G
DCHD (6-82)
E
DAVIE COUNTY HEALTH DEPARTMENT
•" Environmental Health Section.
P. 0. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
�
Name—
Address
ame Date _
Address S� 't'm!Z,- Lot Size 3,
FAr.T(1RC APPA 1 AREA 9 ARFA 3 AREA A
1) Topography/ Landscape Position
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
i) 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
�) 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 S—SUITABLE PS—Provisionally Suitable
Recommendations/Comments:
Described by Title ��� Date
SITE DIAGRAM
UCHD (6.82)