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~Vim- D"IE. COUNTY HEALTH -DEPARTMENT
l ;
- IMPROVEMENTS' PERMIT" AND CERTIFICATE OF "COMPLETION
;NOTE: Issued,in Compliance with G;& of North Carolina Chapter 130 Article.'1.3c
Sewage:Treatment and,Disposal Rules (10.NCAC,10A,.1934-.1968)' Permit Number
Name �� F.lIt � Date — 11 - �' 5134
Location •. o " a;cs Ir,'' -vs . .
4L Vj X10
Subdivision Name Lot-No Sec. or Block No:
Lot Size u
House Mobile Home'" Business __ Speculation
,
No. Bedrooms _ No.'Bathi�"�� No. in Family "
- —
Garbage Disposal" YES -0 NO ' _
_ 1, .� � t Specifications .for System: ,.
Auto Dish Washer YES ❑-. NO ' l j rj
Auto Wash Machine YES• D/ NO ,� 3� . ' ►
i
Type Water Supply
*This permit Void if.sewage system described below is not installed within 36 months from date 'of issue.
Improvements permit' by --
`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
a
I� Certificate of Completion ` E�` Date 1J a
'.The'signing of this certificate shall indicate that-the system desc ibed,above. has, been installed`in compliance -with'
the,standards setforth in the above regulation, but shall in NO.waj9e taken.as a guarantee that'the system will function
y,
satisfactorily for angiven period,of"time. '��:
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section RECEIVED
Mocks Ole, N.C. 7028 RECEIVED APR o 8
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone low" `
1. Permit Requested By &AaA c%aa.y Business Phone
2. Address Pl G 6� /7(-/-
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 Mobile Home ✓ Business
Industry Other
b) Number of people "s
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions
Bed Rooms Z Bath Rooms �2 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 Private Community
b) Has the water supply system been approved? Yes No
9. a) Property Dimensions /450","4''
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?
This is to certify that the information is correct to the best of my knowledge.
y'8 Bey /1jl a G
Date Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
i AM/ L-6u J c/. 7- Zee* ,8r�. cu.k c��•s �o
C�r c�- /�-�' p/.:� �i /�!�C,5,�. /3/9� - /`sl`jiJ.js" .•- /ci�,
DCHD(6-82)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
R O. Box 665
Mocksville, N.C. 27028
(� SOIL/SITE EVALUATION
Name— Date "'
Address Lot Size �'`kQj 'P
FACTORS ARE Cl -' AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position s p
,. S PS
2) Soil Texture (12-36 in.) Sandy, S S
Loamy, Clayey, (note 2:1 Clay) PS PS
U U U U
3) Soil Structure (12-36 in.) S S
Clayey Soils PS PS
U U U U
4) Soil Depth (inches) S S
<:�- p & PS PS
U U U U
5) Soil Drainage: InternalS S S
p§` PS PS
U U U U
External � <:; PS PS
U U U U
6) Restrictive Horizons
7) Available Space ( ���� S S
PS PS
U U
8) Other (Specify) S S S S
PS PS PS PS
U U U U
9) Site Classification
U—UNSUITABLE S—S PS—Provisionally Suitable
Recommendations/Comments: ';�y IZA
Described by Title R,a.- --�� Date �l
SITE DIAGRAM
r
DCHD(6-82)