196 Myers RdIn
,;
DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
"NOTE: Issuedn Compliance with G.S. of North Carolina Chapter 130 Article 13c
Sewage Treatment and Disposal Rules (10 NCAC 10A .1934-.1968)_ Permit Number
Name Zy S a ��- �.� � — Date �� ~ 6 N2 or -C-11
Location ���'� � c� ��o c\--; ; v Q
` Lot No - Seca or Block No.
Lot Size> ys �g�t ' House Mobile Home _ 4 Business Speculation
No. Bedrooms No. Baths _L_ No. in Family 3
Garbage Disposal YES p NO p' Specifications for System:
Auto Dish WasherYES p NO
Auto Wash Machine YES p' (�NO C] r,
Type Water Supply `�- �' _ `rte
'3.
'This permit'Void if sewage system described below is not installed within 36 months from date of issue.
Improvements permit by y
*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 Piagram:
f�
System Installed by
M`�
Certificate of Completion Date - l
"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.
r , 0,66
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section j)
P. O. Box 665 `/9!
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
_ Home Phone i'I LQ 412 a
1. Permit Requested By Business Phone
2. Address - g , �0 �0�(- ►'Y10 CkSvc f le.
3. Property Owner if Different than Above
Address P -A", a Moc-k5L;\ I le -
4.
e4. 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
IndustryOther
b) Number of people s 3
6. aJ If house or mobile home, state size of home and number of rooms.
House Dimensions 141 X90
Bed Rooms 3 Bath Rooms _i/ -P � Den w/Closet
b) If Business, Industry or Other, State: Number of persons served
What type business, etc.
Estimate amount of waste daily (24 hou
7. Number and type of water -using fixtures:
commodes.
lavatory —
dishwasher
urinals
showers
sinks
garbage disposal
washing machine
8. a) Type water supply: Public ✓ Private Community
b) Has the water supply system been approved? Yes Noye+
9. a) Property Dimensions To„gulAv �cJ } or ��/prs fid. � Sri; Ilry.a,-, 261
b) Land area designated to building site
c) Sewage Disposal Contractor
10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve? ' `o
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:
A,-.,4 (P"y e- d) (�► r,
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I 5+- K) -')n 1-951. -1) )Ve s KGS (D)_As
DCHD (6-62)
��eaSe ,*43-Q'/�of Ur
yy�3- as93
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section.
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name— Date
Address Lot Size
9=Ar:Tf1RC
AR4� AR� AR� A R �
1) Topography/ Landscape Position
S
S
�3
U
S
U U
2) Soil Texture (12-36 in.) Sandy,
Loamy, Clayey, (note 2:1 Clay)
S
S
PS
S
U
U
3) Soil Structure (12-36 in.)
Clayey Soils
S
C–
S
U
U
U
I) Soil Depth (inches)
P
U
U
U
U
i) Soil Drainage: Internal
S
PS
U
U
U
External
'ZjPS
PS
U
U
U
i) Restrictive Horizons
Available Space
pi)
S
U
U
U
o) Other (Specify)
S
PS
S
PS
S
PS
S
PS
1) Site Classification
U—UN\SUIUITABLESUITABLE �l PS—Provisionally
endations/Comments: \'� \ � ��"'� \(V' 3 (Z'
) A6\
Described by Title Date
SITE DIAGRAM
DCHD (6-82)