146 Scenic Dr DAVIE COUNTY HEALTH DEPARTMENT
{ 1 IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTE. Issued in Compliance with G.S. of North Carolina Chapter 130 Article 13c
S a e Treatment and Disposal Rules (10 NCAC 10A .1934-.1968) Permit Number
Name �)i �)i / .1 Date ,/ -�%%r N2 �`25, 6
Location, / rtl t � l�, /° ,r�.%>� ,t r7l
Subdivision Name Lot No. Sec. or Block No.
Lot Size .J.�49196 House_ Mobile Home _ Business Speculation
No. Bedrooms No. Baths Z No. in Family Z
GarUdge-Disposal YESfl NO �' Specifications for,System-
Auto Dish Washer YES NO ❑ �/1yi9 �' `. ,/, (10`9*
Auto Wash Machine YES � NO p ��
Type Water Supply
*This permit Void if sewage system described below is not installed within 36 months from date of issue.
F
Improvements permit b -i
*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
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*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.
ik
r " PPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT V�2
Davie County Health Department
bEnvironmental Health Section
P. 0. Box 665
_ Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERW IT HAS BEEN ISSUED.
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%✓� P Home Phone a S J
1. Permit Req ested By — LkO Business Phone
2. Address
3. Property Owner if Different than Above
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 type facility: House--it--I/Iobile Home Business
Industry Other
b) Number of people
6. ay If house or mobile home, state size of home and number of rooms.
House Dimensions
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 l - showers f washing machine
dishwasher sinks
8. a) Type water supply: Public—Private Community
b) Has the water supply system been approved? Yes No
9. a) Property Dimensions I a 5 K D_()(3
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?
What type?
Thisisto certi 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:
57 —
Ly
7
DCHD(6-82)
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DA VIE COUNTY HEALTH DEPARTMENT
Environmental Health Section.
P. 0. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION 7
Name 1�°� Date
Address Lot Size
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position S S S
P PS PS PS
U U U U
2) Soil Texture (12-36 in.) Sandy, S S S
Loamy, Clayey, (note 2:1 Clay) PS PS PS PS
U U U
3) Soil Structure (12-36 in.) S S S
Clayey Soils PS PS PS
U U U
4) Soil Depth (inches) S S S
PS PS PS
U U U
5) Soil Drainage: Internal S S S S
PS PS PS
U U U
External S S S
PS PS PS
U U U
6) Restrictive Horizons
7) Available Space S S S S
PS 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 /;
U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable
Recommendations/Comments:
Described by / Title Date
SITE DIAGRAM
DCHD(6.82)