137 Liberty RdDAVIE COUNTY; HEALTH DEPARTMENT
IMPROVEMENTS PERMIT. AND :CERTIFICATE OF COMPLETION"
*NOTE: Issued in Compliance with; G S of:-North Carolina• Chapter 130 Articlei 13c., �+
. Sewage Treatment and Disposal Rules (10 NCAC 1.OA .1934-:1968) Permit Number
-4Name Date I
-�12
;Location `� cam. 'itiU�' \ r ' . "i S`;, ii�)
i� `\� a-..1+. `�` ,:� "'R'C^•^_ R __'I cam\ ) �i li t a...S: i,n...
1 Subdivision NarT a Lot No: Sec nr Rln'rk Nn
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APPLICATION FOR SITE EVALUATION/ IMPROVEMENTS PERMIT`;:,'`•,
Davie County Health Department
Environmental Health Section
P. O. Box 665?
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone Q ��/- < L _)-1
1. Permit Requested By � - - a ✓- Business Phone t�; -A / Fq"-7
2. Address -
'S G �/ ,L, .»E'
3. Property Owner if Different than Above G� r�e iyi AI o e Y'
Address 21 7 &— �� _y.- ZZDC_-ef, / _fi!
4. Permit To: a) Install 'Alter Repair
b) Privy Conventional--L----Other Type
Ground Absorption
c) Sub -Division Sec. Lot No.
5. System used to serve what type facility: House_.L:'_"Mobile Home Business
Industry Other
b) Number of people I
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions 4j 9 � /
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 garbage disposal
lavatory - showers- washing machine /
dishwasher sinks
8. a) Type water supply: Public t/ Private Community
b) Has the water supply system been approved? Yes ✓No
9. a) Property Dimensions
b) Land area designates
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 to the best of my knowledge.
Date Owner Sign ture
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
" �'-er I/
!D0- 5 /)'
DCHD (6-82)
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c`2 G �L
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
R O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name Date -� c�
Address Lot Size own
FACTORS AREA 1 ARFA 9 ARFA 3 AREA d
1) Topography/ Landscape Position
S
S
S
db
PS
PS
PS
U
U
U
U
2) Soil Texture (12-36 in.) Sandy,
S
S
S
Loamy, Clayey, (note 2:1 Clay)
&P
PS
PS
PS
U
U
U
U
3) Soil Structure (12-36 in.)
S
S
S
Clayey Soils
&
PS
PS
PS
U
U
U
U
1) Soil Depth (inches)
S
S
S
k
PS
PS
PS
U
U
U
U
i) Soil Drainage: Internal
S
S
S
PS
PS
PS
U
U
U
U
ExternalA
S
S
S
PS
PS
PS
U
U
U
U
i) Restrictive Horizons
Available Space
S
S
S
pS
PS
PS
PS
U
U
U
U
o) Other (Specify)
S
S
S
(t
PS
PS
PS
U
U
U
U
1) Site Classification
,
U—UNSUITABLE
Recommendations/ Comments:
Described by
SITE DIAGRAM
DCHD (6-82)
S—SUITABLE PS rovisionaliy Suitable
Title �\titi"^-o,s Date