P4576 Howell Rd. ..+.«.:.-�•:a«--..y,.. i•.,'.t.n)_a:.. y:c l....:a.,+.�r.L.�w:>. �.:+' ...••..+�.. r.L.:: S.Ytn.- .�. .t .. • n .. • m 71
-
1�.
DAVIE COUNTY HEALTH DEPARTMENT
11 .. IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
'NCTE:-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
�
T�
Name "�r., ' ��,, j Date 1
Location �' ,�-: � �- � - i� ,; /� .,�,' ,� : t7 ,.__-^_;ter✓
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 ❑ Specifications for System:
Auto Dish Washer YES NO ❑ " /,
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.
Improvements permit by _7--��
"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.
—Z—
Final
L
Final Installation Diagram:
a
System Installed by
Certificate of Completion
Date
/?,Cr�/i
'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.
RECEIVED NOVO 5 1986,
APPLICATION FOR SITE EVALUATION/ IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section
P. 0. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
1. Permit Req ested By e
2. Address _-Zv '? A.0 ze,3
Home Phone 9 9 8- 3 Z D
Business Phone
3. Property Owner if Different than Above
Address
4. Permit To: a) Install Alter Repair
b) Privy—
nventAnal Other Type / C 4A,
!, /L ��
round Absorption �l Y -
c) Sub -Division Sec. Lot No. /�-"
5. System used to serve what type facility: House Mobile Home Business U,tio44u. vgft12�
Industry Other
b) Number of people .7-
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions J4.X 6
Bed Rooms 2 Bath Rooms Den w/Closet 2-
b) If Business, Industry or Other, State: Number of persons served
What type business, etc.
Estimate amount of waste daily (24 hours) WS
7. Number and type of water -using fixtures:
commodes 1__�' urinals
lavatory
showers
dishwasher sinks .1
8. a) Type water supply: Public Private�� Community
b) Has the water supply system been approved? Yes No
9. a) Property Dimensions X 3
b) Land area designated to building site
garbage disposal
washing machine
c) Sewage Disposal Contractor
10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve? No
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:
&o/ N 9/0 & APw auwch - Vo-tvew Rt - A /,0/- yzeude,
DCHD (6-82)
{
-r DAVIE COUNTY HEALTH DEPARTMENT
. _ Environmental Health Section
R 0. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name Date
Address Lot Size
FACTORS AREA 1 AREA 2 AREA 3 ARFA 4
1) Topography/ Landscape Position
S
S
S
PS
PS
PS
U
U
U
U
?) Soil Texture (12-36 in.) Sandy,
S
S
S
S
Loamy, Clayey, (note 2:1 Clay)
F)
PS
PS
PS
U
U
U
U
1) Soil Structure (12-36 in.)
S
S
S
S
Clayey Soils
j
PS
PS
PS
U
U
U
i) Soil Depth (inches)
S
S
S
pS
PS
PS
PS
U
U
U
i) Soil Drainage: Internal
S
S
S
PS
PS
PS
PS
U
U
U
U
ExternalS
S
S
S
PS
PS
PS
U
U
U
i) Restrictive Horizons
d----
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
1) Site Classification
U—UNSUITABLE
Recommendations/ Comments:
Described by _
SITE DIAGRAM
DCHD (6-82)
S—SUITABLE PS—Provisionally Suitable
Title Date