P4404 Hwy 601SAAA, DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTE: Issued in -Compliance with G.S. of North Carolina Chapter 130 Article 13c
Sew ge 'Treatment
- and. Disposal Rules (10 NCAC 10A .1934-.1968)- Permit Number
Name i i -/Jri' / I �� Date _�/ �:} �. `; t fr 1) 4
Locations
Subdivision Name Lot No. Sec. or Block No.
Lot Size House Y-/, Mobile Home _ Business Speculation
No. Bedrooms tom' No. Baths' �! No. in Family �—
Garbage Disposal YES p NO [Z'" Specifications for System:, ) �'
Auto Dish Washer YES NO p ,� .;� "� ,�` ('"
Auto Wash Machine YES j 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 —T
*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:
P Cn c F <s Cc,
Certificate of Completion Date
ii
*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.
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name—�'���'���� Date
Address Lot Size
FAr;TOPA ARFA 1 ARFA 2 ARFA:3 ARFA A
I) Topography/ Landscape Position
S
Ste,
��
S
PS
S
PS
U
U
U
U
'.) Soil Texture (12-36 in.) Sandy,
Loamy, Clayey, Clay)
S
PS
S
PS
(note 2:1
P
U
U
U
1) Soil Structure (12-36 in.)
Clayey SoilsPS
P/ 5/
S
PS
S
PS
U
U
y Soil Depth (inches)
S
PS
S
PS
pg
4A>
U
U
U
i) Soil Drainage: Internal
PS
S
PS
S
PS
S
PS '
U
U
External
PS
S
S
PS
S
PS
�
U
U
U
i) Restrictive Horizons
Available Space
�'
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
Q�
5.."
U—UNSUITABLE S—SUITABLE e" PS—Provisionally Suitable
Recommendations/ Comments:
Described by .%�/ / Title
SITE DIAGRAM
DCHD (6.82)
Date l�C�
a �
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT ✓(J4
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
2. Address —
_ Home Phone 919- 7 G G - 45'1Y e1
By oyfi L V e r), ar-�- Business Phone 26:!L- 3 O
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 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_T
Bed Rooms— Bath Roomsa j� 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 (9 garbage disposal
lavatory S showers 0. washing machine
dishwasher / sinks J
8. a) Type water supply: Public PrivateCommunity—
b)
om unity
b) Has the water supply system been approved? Yes No
9. a) Property Dimensions / '5- J? JO e r -Li
s
b) Land area designated to building site
c) Sewage Disposal Contractor ►per - r� �- f ,ti �� �t� 4, >`` �c. e �►-�
10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve? A�
What type?
This is to certify that the information is correct to the best of my
Date ner Sig ure
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE QTH ALL STATE AND LOCAL LAWS
Directions to property:
DCHD (6-82
Allow 5 days for processing