683 Dulin Rd DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*Note: Issued in Compliance with G.S. of North Carolina Chapter 130—Article 13c.
Permit Number
Name !� ,r\��,c.. ��� �;a �� E Date 4 2 2
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Location -)I , \ , r. ? �` F 1--`l :, - i`, 1 ��� •_,;z' Vj
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Subdivision Name Lot No. Sec. or Block No.
Lot Size �.l Q( c Cs House Mobile Home _ Business -- Speculation
No. Bedrooms No. Baths Z No. in Family 1
Garbage Disposal YES ❑ NO p- Specifications for System:
Auto Dish Washer YES ❑ NO ❑" U <-� - ,}c�
Auto Wash Machine YES p' NO i❑
Type Water Supply 0311 1,11k.
1
*This permit Void if sewage system described below is not installed within
I36 months from date of issue.
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CA
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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
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Certificate of Completion _ Date
*The signing of this certificate shall indicate that the system describeg 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.
r DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
R O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name 1�N,Nr£ �t7ANeE L Date
Address �Tf 3 Lot Size 5V Aca"
f1iLt�cGsVlLct /IAC 'Z7o2Y
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position S S S S
PS PS PS PS
U U U U
2) Soil Texture (12-36 irt�SandyL S S S S
Loamy, Clayey, (note 2:1 Cla ) PS PS PS
8 U U U
3) Soil Structure (12-36 in.) S S S S
Clayey Soils PS PS PS PS
U U U U
4) Soil Depth (inches) S S S S
PS PS PS
U U U
5) Soil Drainage: Internal S S S S
PS PS PS
U U U U
External S S S S
g PS PS PS
U U U
6) Restrictive Horizons
7) Available SpaceQS
S. S S
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 SPS S
Title SA14i 7AR-tAN Date 91-27--r2—
SITE
2ZrZSITE DIAGRAM
DCHD 6-82
J
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section
R O. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEQN' ISSUED../
Home Phone
1. Permit Request d By �� '� Business Phone
2. Address
3. Property Owner if Different than Above
Address
4. Permit To: a) InstallAlter Repair
b) Privy Conventional Other Type
Ground Absorption
c) Sub-Division Sec. Lot No.
5. System used to serve what type facility: Houser Mobile Home Business
o-� IndustryOther
b) Number of people
6. a) If house or mobile home, state size of horand number of rooms.
House Dimensions 3D' --
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 showers washing machine
dishwasher sinks
8. a) Type water supply: Publickff:L_Private Community
b) Has the water supply system been approved?Yes No
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?
This is to certify that the information is correct to the best of my knowledge.
!a DC'yMal J�l OL
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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1
DCHD(6.82)