P5916 Fletcher St low
DAVIE COUNTY HEALTH DEPARTMENT-
'IMPROVEMENTS
EPARTMENT-'IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTE:Issued in Compliance With Article 11 of G.S.Chapter 130a
Sanitary Sewage Systems Permit Number
NamenDqtp N2 59H
-
Location �h/.� r�37` � /!�/�_`r'i';M.r -- ?�^.,a��.� v ,�:�:�'��i E ,t
Subdivision Name Lot No. Sec. or Block No.
Lot Size House Mobile Home _ f::�: Business Speculation
No. Bedrooms .1 No. Baths No. in Family —
Garbage Disposal YES ❑ NO Z' Specifications for System:
Auto KDish Washer YES NO ❑ ` , Ae Z
Auto Wash Machine YES NO ❑ �, -, '
Type Water Supply
*This permit Void if sewage system described below is not installed within 5 years from date of issue.
This permit is subject to revocation if site plans or the intended use change.
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Improvements permit b _ e!g
*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: System Installed by
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Certificate of Completion Date. 7h�k
The signing of this certificate shall indicate that the system described above has been installed]n 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.
46 APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
• * Davie County Health Department
*` Environmental Health Section
P. O. Box 665 C _LVED MAR 2
Mocksville, NC 27028 �E
1 . A lication/Permit Requested By 0..�- � 4
PP _
Mailing Address Qt -7 f WC-
Home Phone P-S 9Business Phone
2. Name on Permit if Different than Above
3. Property Owner if Different than 'Above
4. Application/Permit For : 0 General Evaluation eS/Tank Installation
5. System to Serve: House I"46bile Home 0 Business
Industry0 Other 0 Unknown
6. If house, mobile home: Subdivision Sec. Lot#
No. of People I Dwelling Dimensions
No. of Bedrooms Basement/Plumbing
No. of Bathrooms Basement/No Plumbing
0 Washing Machine J Dishwasher 0 Garbage D:isposai
7. " If business, industry, other: Specify type
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No. of People Served No. of Sinks
No. of Commodes No. of Urinals
No. of Lavatories No. of Water Coolers
No. of Showers
8. Type of water supply: a--,Public 0 Private Community
9. Property Dimensions 7 a-c.-,�
10. Sewage Disposal Contractor
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11 . Do you anticipate additions/expansions of the facility this system is
intended to serve? 0 Yes a,"No
If yes, what type?
*NOTE: Improvements Permits shall be valid for a period of 5
years from date issued. Improvements Permits are subject
to revocation, if site plans or the intended use change.
Effective October 1, 1989.
This is to certify that the information provided is correct to the
best of my knowledge, and I understand I am responsible for all
charges incurred from this application.
L10 a �
Date Signature
Directions to Property : /f74. Zf
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DCHD (10-89)
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„r DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section.
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name ,!�l1't�E Date
Address Lot Size &'4e-
FACTORS AREA 1 AREA2 AREA 3 AREA 4
1) Topography/Landscape Position O a ® 69
PS PS PS PS
U U U U
2) Soil Texture (12-36 in.) Sandy,
Loamy, Clayey, (note 2:1 Clay)
U U U
3) Soil Structure (12-36 in.) S
Clayey Soils CR PS P
U U U
4) Soil Depth (inches) <4
S S
P1 PS
U U
5) Soil Drainage: InternalJR
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U U U $)
External S
L.P�9 P_
PS
U U U
6) Restrictive Horizons
7) Available Space is PS PS PS
U U U U ,
8) Other (Specify) S S S S
PS PS PS PS
U U U U
9) Site Classification - 1
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U—UNSUITABLE S—SUITABLE _ PSS,Provisionally Suitable
Recommendations/Comments:
Described byY� LTitle Date
SITE DIAGRAM
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DCHD(6.82)