3205 Hwy 801SDAVIE 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 .1/934-.1968) -,Permit Number
/
Name 7-� 1�,.1icf� Date �zo -,&q ' 432
Location ? '-111ei's Aloe–�� ar i'e
G -'i` s�s� ��� Eo ,��� 1C'f1r) -
-�/� C/o ! S�
Subdivision Name Lot No. Sec. or Block No.
Lot Size % c- House Mobile Home Business Speculation
No. Bedrooms 'L. No. Baths — No. in Family —
Garbage Disposal YES ❑ NO ❑
Specifications for System: jppp
Auto Dish Washer YES ❑ NO ❑
Auto Wash Machine YES ❑ NO -❑ 700 3 x i z = inr'f-
Type Water Supply COVN-i y _ 1�- max a�� cor•crc£r�
*This permit Void if sewage system described below is not installed -within 36 months from date of issue.
a_NS 1j 1 7t irR�c t
Improvements permit by �" s
*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.
A—,,;,
Final Installation Diagram: System Installed byLAV
�`�� rz_
Certificate of Completion`_L� Dater
The signing of this certificate shall indicate that the system described above has been installed in compliance with
standards set forth in the above regulation, but shall in NO way be taken as a guarantee that the system will function
,,f\ torily for any given period of time.
C
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
R 0. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name -Z)oa R'411 � Date -
Address %ZT Z %cam �f� Lot Size
V,4, -JC -E- //L
�errn[zc AREA 1 AREA 9 AREA 3 AREA 4
Topography/ Landscape Position
9)
SPS
PS
U
U
U
U
!) Soil Texture (12-36 in.) Sandy,
S
S
S
S
Loamy, Clayey, (note 2:1 Clay)
1�p
�.5�
PS
PS
U
U
U
U
1) Soil Structure (12-36 in.)S
4P-
S
PS
S
PS
Clayey Soils
U
U
U
U
Soil Depth (inches)
(T�:>
��
S
S
PS
PS
PS
PS
U
U
U
U
i) Soil Drainage: Internal
(19!�
Q�)
S
S
PS
PS
PS
PS
U
U
U
U
External
C�
(9�)
S
S
PS . „
PS
PS
PS
U
U
U
U
i) Restrictive Horizons
Available Space
S
PS
S-
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 C PSLProvisionally Suitable
Described by - Title
SITE DIAGRAM
DCHD (6-82)
Date 3'u - Q
• APPLICATION FOR SITE EVALUATION/ IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section/
R O. Box 665
Mocksville, N.C. 27028
1. Permit F
2. Address
3. Property
Address
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
4. Permit To: a) Installer 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
IndustryOther
b) Number of people
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions ?'L ZQ
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 urinals
lavatory showers
dishwasher sinks _
8. a) Type water supply: Public Private Community
b) Has the water supply system been approved? Yesk-No
9. a) Property Dimensions 4x co
b) Land area designated to building site
garbage disposal /r�1
washing machine
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 the best of my knowledge.
_3hohV
Date Owner Sign ure
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
:5201 Y2. a4e-�� '3Z21tA0
Ao�& Aj e -
DCHD (6-82)