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DAVIE COUNTY HEALTH DEPARTMENT xgY
a IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
NOT : '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
Date f
i �
Location �-5 -��if Y .s,'�/�%✓,, Fes' �<' �� f ` ..ri,,�.� r �y�_s-�'y''
Subdivision Name
Lot No.
Sec. or Block No
Lot Size House Mobile Home v� Business Speculation
v
No. Bedrooms-2—No. Baths ,��1 No. in Family
Garbage Disposal YES ❑ NO 12� Specifications for System -
Auto
Auto Dish Washer YES NO ❑ / `-' '4) -G X
Auto Wash Machine YES NO -E]`��` /'
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
i
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.
E
~~ APPLICATION FOR SITE EVALUATION/ IMPROVEMENTS PERMIT ��Ut p 9
Davie County Health Department ,986
Environmental Health Section
R O. Box 665
Mocksville, N.C. 27028 C �iJ �,C
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
0/9)
Home Phone 7(0 7#Y- (E44u1 J'1mk ))
1. Permit Requested By
.70'»719-)U'f S- Bttsmess Phone 176,7-671.7 Yvk • 17-q
2. Address %JO !o -y fO i Id 1 ,jt, IX x'706 „
3. Property Owner if Different than Above
Address
4. Permit To: a) Install Alter Repair
b) Privy Conventional Other Type
Ground Absorption
c) Sub -Division Sec. Lot No.
5. System used to serve what type facility: House Mobile Homey Business
Industry Other
b) Number of people 2
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions lq X &0
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 a urinals garbage disposal
lavatory a showers washing machine
dishwasher sinks /
8. a) Type water supply: Public Privateer Community
b) Has the water supply system been approved? Yes No
9. a) Property Dimensions J a070.,__
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.
Date Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
ly
a� .Qin.d., e/ aC&nO h4 of t� <�I.ea2 k,4.t &41n j � J140) - �vLte .0)IC/u
DCHD (6-82)
Address
FACTnRB
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. 0. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Date 2ZOd
Lot Size ,&�
AREA 3 ARFA d
ARFA 1 ARFA 9
1) Topography/ Landscape Position
9)
S
dp
�
S
PS
S
PS
U
U
U
U
'.) Soil Texture (12-36 in.) Sandy,
Loamy, Clayey, 2:1 Clay)
PS
S
PS
S
PS
(note
U
U
U
U
1) Soil Structure (12-36 in.)
Clayey Soils
S
C—IJ
S
PS
S
PS
U
U
G) Soil Depth (inches)
S
S
g
PS
PS
PS
U
U
�) Soil Drainage: Internal
PS
is7l
S
PS
S
PS
U
U
External
f
___----
S
PS
U
S
PS
U
i) Restrictive Horizons
Available Space
�S�
PS
PS
S
PS
S
PS
U
U
U
U
1) 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 f / Title
SITE DIAGRAM
DCHD (8.82)
Date