P3553 Gladstone Rd' DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION �.
*NOTE: Issued in Compliance with G.S. of North Carolina Chapter 130 Article 13c f
Sewage Treatment and Disposal Rules (10 NCAC 10A .1934-.1968) Permit Number
Name �l-- �... `�� Date <".`E?ed r z
Location
- =T—
bdivision Name
Lot No. Sec. or Block No
Lot Size _ House Mobile Home _ r_% Business Speculation
No. Bedrooms �.. _ No. Baths No. in Family--
Garbage
amily Garbage Disposal YES ❑ NO ❑ Specifications for System:
Auto Dish Washer YES ❑ NO ❑ /�% v7 L
Auto Wash Machine YES ❑ NO -❑
Type Water Supply _
*This permit Void if sewage system described below is not installed within 36 months from date of issue.
...--'"`r��..�.-_•_--
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
Certificate of Completion _� QM1J Date
*The signing of this certificate shall indicate that the system describA 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
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
J SOIL/SITE EVALUATION
Name— Date '" of�
Address Lot Size
FArTCIRS AREA 1 ARFA 9 ARFA 3 ARFA A
Topography/ Landscape Position
S
S
S
PS
PS
PS
U
U
U
U
'.) Soil Texture (12-36 in.) Sandy,
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
S
Clayey SoilsS
PS
PS
PS
U
U
U
U
1) Soil Depth (inches)
S
S
S
S
PS
PS
PS
U
U
U
U
) Soil Drainage: Internal
S
S
S
PS
PS
PS
U
U
U
U
External
S
S
S
S
PS
PS
PS
U
U
U
U
1) Restrictive Horizons
Available Space
S
S.
S
S
PS
PS
PS
U
U
U
U
1) Other (Specify)
S
S
S
PS
PS
PS
U
U
U
U
1) Site Classification
U—UNSUITABLE S—SUITABLE
Recommendations/Comments:
Described by _
SITE DIAGRAM
DCHD (6-82)
PS—Provisionally Suitable
Title Date
APPLICATION FOR SITE EVALUATION/ IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section
R O. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
1. Permit Reguested By
2. Address
3. Property Owner if Different than Above
Address
4. Permit To: a) Install Alter Repair
b) Privy Conventional Other Type
Ground Absorption
Home Phone q'9 a-
Business Phone &34- 3542 1_
c) Sub -Division Sec. Lot No.
5. System used to serve what type facility: House Mobile Homed Business
IndustryOther
b) Number of people
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions I q x %O
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
lavatory showers )
dishwasher
sinks
garbage disposal
washing machine
8. a) Type water supply: Public Private— Commdnity
b) Has the water supply system been approved? Yes No
9. a) Property Dimensions &6 Sg Acre- 176, 00 X 196. 0 O
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? l0
What type?
This is to certify that the information is correct to the best of my knowledge.
S7 J Aal
Date Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
L
DCHD (6-82)
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