495 Griffith Rd 00
4�. DAVIE COUNTY HEALTH DEPARTMENT
IMP.ROAMEtITS PERMIT ANDCERTIFICATE OF''COMPLETION
_
-"NOTE: Issued in Compliance with G.S. of North Carolina Chapter 130 Article 13c
Se ge Treatment and-Disposal Rules (10 NCAC 10A .1934-.1968) ° Permit Number
Name ;%�'.�er cl�,� Dated'' . 4219 ;
Location 1i1x /T ✓/'Y_ r 5, ,�� C,� _ !ter �_: �l "
Subdivision Name _ Lot No. Sec. or Block.No.. -
Lot Size. 62- House ke!f—' Mobile Home — Business Speculation
No. Bedrooms No. Baths
_ CQ No. in Family
Garbage Disposal YES ❑ NO,;;�J' Specifications for Syst m:
Auto Dish Washer YES NO ❑
Auto Wash Machine YES NO ❑ <- i.
Type Water Supply
*This permit Void if sewage system described below is not installed within 36 months from.date of issue.
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ICFmprovements permit by
*Contact a representative of the Davie County Health Department for final inspection of this yste 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.
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.
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DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name Richard Budd-Rt.1, Advance, NC Date
Address Jason Sheek Lot Size
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position S .) S S S
Lam' PS PS
U U U U
2) Soil Texture (12-36 in.) Sandy, S S S
Loamy, Clayey, (note 2:1 Clay) 4�5) PS PS
U U U U
3) Soil Structure (12-36 in.) S S S
Clayey Soils PS PS
�. U U
4) Soil Depth (inches) S
� -� S S
PS PS
U U U U
5) Soil Drainage: Internal S S S S
!� PS PS
U U U
External S S S S
� 7 PS PS
U U U
6) Restrictive Horizons / / /
L
7) Available Space 4P S S
PS PS PS PS
Ur U U U
8) Other (Specify) S S S S
PS PS PS PS
U U U U
9) Site Classification <
U—UNSUI BLE S—SUITABLE PS—Provisionally Suitable
Recommendations/Comments:
Described byTitle ,!!��v Date
SITE DIAGRAM
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DCHD(6-82)
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APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
h Home Phone
1. Permit Requested By C 14A 1? D P /.3 0 01Business Phone
2. Address R# / A d V A NG E /V,G 3-7006
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 I-Mobile Home Business
IndustryOther
b) Number of people 41=
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions
Bed Rooms Z 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 - showers washing machine
dishwasher sinks /
8. a) Type water supply: Public Privateer Community
b) Has the water supply system been approved? Yes Nom
9. a) Property Dimensions
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? Ma
This is to certify that the information is correct to the best of my knowledge.
Date Owner SignatureY,���a�– �'k/
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)