P4972 Gladstone Rd aT ... ,I
DAVIE,'COUNTY. HEALTH DEPARTMENT
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IMPROVEMENTS PERMIT AND_CERTIFICATE OF COMPLETION
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'NOTE: Issued.in,Compliance with GIBS. of North Carol ina'Chapter 130 Article 13c
Sewage Treatment and Disposal Rules. (10 NCAC 10A ,1.934-:1968) Permit Number
Name ' 1 � � �,;� Date.�l— 4972
Location :S�.: ,}C '�
Subdivision Name i Lot No.' Sec. or Block No.
Lot Size k House.Ii Mobile Home _ Business Sped iulation
No, Bedrooms _ - No..Baths'+ _ No.,jn ,Family
Garbage Disposal YES E] NO� ;i
Specifications for System:
Auto Dish Washer YES . 'NOi .'.
Auto Wash Machine YES NO-
TYpe Water Supply t C-)ill ` '>
"•This permit Void if sewage system dl scribed below is not installed within 36 months from date offissue.
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1 Improvements permit by -= 3�
'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. ;I
Final Installation Diagram: System Installed by.
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Certificate of Completion. // Date j
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The sighing of this certificate shall I'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 betaken as a guarantee that the;systerh will function
satisfactorily for any given p(�iod ofj'time.
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department G
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone 2i8L1-
1. Permit Requested ByMrRt S M c DANIfL oZ ��
Business Phone
2. Address Po • C)X 53 a C 01 ecm��
3. Property Owner if Different than Above T.e r r V Me- D Am-rp. L
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 Homed Business
Industry Other
b) Number of people
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions I y X S 6
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 lwater-using fixtures: '
commodes 1 urinals garbage disposal
lavatory showers washing machine—I
dishwasher sinks
8. a) Type water supply: Public Private Community
b) Has the water supply system been approved? Yes No
9. a) Property Dimensions jar re
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.
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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)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section.
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
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Name c��x? c�s� Date
Address S A `t Lot Size
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position S S
PS PS_ PS
U
2) Soil Texture (12-36 in.) Sandy, S
Loamy, Clayey, (note 2:1 Clay) (10 PS
U
U U
3) Soil Structure (12-36 in.) S S
Clayey Soils �? J(A -F�s PS
U U U U
4) Soil Depth (inches) SS
P PS
U U U
5) Soil Drainage: InternalS
d? ri� —is PS
U U U U
ExternalS S
sp--o !PS:5 —1 PS
U U U
6) Restrictive Horizons
7) Available Space SS
4 PS
8) Other (Specify) S S S S
PS PS PS PS
U U U
9) Site Classification S
U—UNSUITABLE S—SUITABLE PS Provisionally Suitable
Recommendations/Comments:
Described by Title � Date
SITE DIAGRAM
-701
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UCHD(6.82)