P4657 Howell Rdr.'
DAVIE COUNTY HEALTH DEPARTMENT
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
NameZ, Date
r • Dt�
Location ,.�'/:✓ % "' ,, p �!�; , /� / �' - ,�r ;:�}✓ i`;�:1�, // ,_ ��
Subdivision Name Lot No. Sec. or Block No.
Lot Size % ' ' �' House Mobile Home I -' Business Speculation
No. Bedrooms _ No. Baths 92 No. in Family _
Garbage Disposal
Auto Dish Washer
Auto Wash Machine
Type Water Supply
YES ❑ NO ❑-,—
YES NO ❑
YES NO ❑
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.
Final Installation Diagram:
System Installed by
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.
APPLICATION FOR SITE EVALUATION/ IMPROVEMENTS PERMIT
Davie County Health Department c������
Environmental Health Section plj
R O. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
1. Permit Requested
2. Address 9'0 -5
3. Property Owner if Different than Above
Address
4. Permit To: a) Instally Alter Repair ,
b) Privy Conventional P Other Type
Ground Absorption
Home P,ogle �lee 3,?
Business Phone ?Zj— 7T3 -A99 8`
Sfl-L s7yl��VC ®2 7 /a s
c) Sub -Division Sec. Lot No.�—
5. System used to serve what type facility: House Mobile Homed Business
IndustryOther
b) Number of people 3
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions ,/_�� 7y
Bed Rooms 3 Bath Rooms 5�2- 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
lavatory
dishwasher
urinals
showers f
sinks
garbage disposal
washing machine
300
8. a) Type water supply: Public Private kf"� Communityh
b) Has the water supply system been approved? Yes No Q 76
9. a) Property Dimensions
b) Land area designated to building site /SO X 3 o d
c) Sewage Disposal Contractor
10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve? Na
What type?
This is to certify that the information is correct to the best of my knowledge.
Date Owner Si nature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
DCHD (6-82)
Address
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
R O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Date 2// AP'
Lot Size /6i9 0
9ZAr.Tf1RC APPA 1 APPA 7 ARFA R ARFA A
Topography/ Landscape Position
S
S
S
PS
PS
PS
PS
U
U
U
!) Soil Texture (12-36 in.) Sandy,
S
S
S
S
Loamy, Clayey, (note 2:1 Clay)
SPS
PS
PS
U
U
U
1) Soil Structure (12-36 in.)
S
S
S
S
Clayey Soils
PS
PS
PS
PS
U
U
U
i) Soil Depth (inches)
S
S
S
S
PS
PS
PS
U
U
U
i) Soil Drainage: Internal
S
S
S
S
PS
PS
PS
(UJ
U
U
U
External
S
S
S
PS
PS
PS
U
U
U
U
i) Restrictive Horizons
Available Space
qV
S
S
S
S
PS
PS
PS
U
U
U
U
1) Other (Specify)
ns
S
S
S
S
PS
PS
PS
U
U
U
U
1) Site Classification
l
U—UNSUITABLE
_/ S—SUITABLE PS—Provisionally Suitable l
Recommendations/ Comments: iii .dO .� ( ! P o �� e �'z �b U✓�` �/� N/��'i{�x/
-��
Described by Title Date
SITE DIAGRAM
DCHD (6-82)