214 Abbey Ln " � _ �.
'_` :� ••, , !DAVIE �COUNTwIf ;HEALTH iDEPARTMENT ., 3u
"�� • �.S I IMPROVEMENTS; PERMIT ,AND CERTIFIGATE; OF' COMP,LETION �
':Note`IssuaC.iri Compllerice ivith�G!S.�bf NoitfiiCeFbline Gliapter;l3�Article��l8c. �
P.ermit Numtie►
�u..e .H. �et�.ni.L 'L, - z� -83 �.Iu 32�2
Neme� , - - —�Date
l!dcatibn ��,iexi�ll ii.� - ��'w_ da l� �i �b� P+�� �.�1t br�.cl�s .
rt a 0.,�i l000 F-E r� u.ur �r�.e._. rn.• L� �'.'��y��Afil7El/ 1/')NG�
�Sutidivisian'Name Lol!No. �'Sec:�6�•BloclilNo:
L�ot Size• - 5 n�� �iHouse - Mobile�Homei� '� Business� - - -�Speculefion�
No: Bedrooma� -- Z .No: Baths. � No. In F:emlly, L"
Gaitiege+Disposal N.ES ❑ NO� p � !Speoificationa 'fo`r� System:9W �u0� i°1-�'
�AutoiDish'Weshei �Y,ES •p�NO. p� ! �;si• 'kS•F - zoo' % :"X�x 'n'+/L
P:uto;WashlAAechine� YES pp NO �p
Sype Wate�:SuPB�Y . . �w��.�. . . . . .. '
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'Tliisiperrriit'Void if'seviege aystem deeciib�ede6elow:isinbt instelled�viitfiine36ymonths from�dete;of issue..
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Improva"mentsSpeimittiy�.�\�1a^^ -
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'Coritaotee�'representeti4e:bf tlie'�DsGieiEounry'Flealth,Depertrrment for':flnel' Inepectlbn of•tfii's systemi ti�elween!8:30-
i9:30,A�M:'ai���T:00=.1:30 �P.M. on d'ay+of completion. �Iephone:Number: 704-834.;5885.
F.Inel+lnalellstl6n Disgiem:� System�lnstalletl tiy, ����`���-��
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Eertificaterof•Completion �w"��-� �iDate-����z
'TFie signing,_oK•ifiis=certificete•sKall;Intilcate tKflt'the 'systein descri6eH aboJa h"es��6ee'n instslle0 in�coinpliariee witli
�Ihe sten'tlertls;seKforth'�initfieiatiovelieguletion.itiuf shell:iniNO,wsy tie�tsken'as�A'guarentee�tfiahtfie!systemiwill;fOnction
satisiactorily�fouany,given�periotl�of�time. " '
, ,
x .�.�! � , , DAVIE COUNTY HEALTH DEPARTMENT � � �
� � IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
`Note: Issued in Compliance with G.S. of North Carolina Chapter 130—Article 13c.
Permit Number
Name •- . ., . , . �__ Date �� -- , ... " _. �� ..
Location ', � � � ; _ � i � " � _ , _
� - - ' ' _ `,� - __ �- �I �l l�b��i �N�,
Subdivision Name Lot No. Sec. or Block No.
Lot Size '' ' House Mobile Home _' "� Business -- Speculation
No. Bedrooms �� No. Baths r No. in Family `"" _,
Garbage Disposal YES ❑ NO �� Specifications for System: `;' :.�� '� << � �' + '' - �" '
Auto Dish Washer YES ❑ NO 0' , -, , _ _ �. � _ � . � � ,_ .
Auto Wash Machine YES Q`� NO �
Type Water Supply � �•� � � __—
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"This permit Void if sewage system described below is not installed within 36 months from date of issue.
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Improvements permit by� - ' � '� `��"` r` � .: ''
*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.
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Final Installation Diagram: ���� System Installed by ''="
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Certificate of Completion r ��' ` - Date - - ; �� `" � ����
#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 `�v�nc rct.ti�'.L. 'Z�21-�3
Date
Address ��`� ����. l�.- � Lot Size S Q��-
t,,J -.S
1) Topography/Landscape Position
2) Soil Texture (12-36 in.) Sandy,
Loamy, Clayey, (note 2:1 Clay)
3) Soil Structure (12-36 in.)
Clayey Soils
4) Soil Depth (inches)
5) Soil Drainage: lnternal
External
6) Restrictive Horizons
7) Available Space
8) Other (Specify)
9) Site Classification
U—UNSUITABLE
Recommendations/Comments:
AREA 1
S
�
U
�
U
�
U
�
PS
U
�
�
PS
U
✓
`�P5
u
s
PS
U
S
S—SUITABLE
�REA 2
�
U
S
�
S
�
U
�
PS
U
S
�
PS
U
�-
u
s
PS
U
>�
AREA 3
S
PS
U
S
PS
U
S
US
PS
U
S
PS
U
PS
U
S
PS
u
s
PS
U
onaliy Suitable
AREA
S
PS
U
S
US
S
US
PS
U
S
PS
U
PS
U
S
PS
u
s
PS
U
Described by ��"�" Title ���� � Date 2� Z�"� �3
,..�. . �
SITE DIAGRAM
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DCHD (6-82)
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• ' � APPL'ICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT �� �� �
Davie County Health Department � �
Environmental Health Section ��' �
y
P. O. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
� Home Phone 7Z 4� - /3�d
1. Permit Requested By Business Phone �Q�— ����
2. Address � •C�
3. Property Owner if Different than Above ��+o
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 rype facility: House Mobile Homel� Business
Industry Other
b) Number of people T��
6. a) If house or mobile home, state size of home and number of rooms.
.
House Dimensions �.2 x 60�
Bed Rooms � Bath Rooms � Den w/Closet �
b) If Business, Industry or Other, State: Number of persons served �t�e
What type business, etc. �t/G-�, �-
Estimate amount of waste daily (24 hours),� �nc �����
7. Number and type of water-using fixtures:
commodes t urinals garbage disposal
lavatory I showers washing machine �
dishwasher sinks �
8. a) Type water supply: Public Private Community—��
b) Has the water supply system �een approved? Yes��No
9. a) Property Dimensions 1� �-�� �—���° ���''�
b) Land area designated to building site
c) Sewage Disposal Contractor �!/O� �eur,� �tr� ✓T �P1'e�stf �lyLE'_
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.
� .� /d - �.�
Date Owner Signature
` OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
.
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DCHD (6-82)