P5546 Buckingham Ln y!F ,:E rx/'.u.V_..M.e:r •.. .. s4i� f...y.a•�,W4. ..a}. r.S.: ` -a �r . - ♦ra • •.. .�♦
DAVIE COUNTY HEALTH DEPARTMENT �' r
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION ' 3 3
"NOTE: Issued in Compliance with G.S. of North Garolina Chapter 130 Article 13c
Sewage Treatment and Disposal Rules (10 NCAC 10A .1934-.1968) Permit Number
` Name Date No 5546
Location.
Subdivision Name Lot No. Sec. or Block No.
Lot Size House House Mobile,Home Business Speculation
No. Bedrooms_3 No. Baths f No. in Family
Garbage Disposal YES ❑ NO Specifications for System:
Auto Dish Washer YES ❑ NO
Auto Wash Machine YES NO ❑ k�
:3 -3
Type Water Supply Z� U Z�,�'_ --
*This permit Void if sewage system described below is not installed within 36 months from date of issue. ,'a
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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 Completi8n - + 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 thesystem will function
satisfactorily for any given period of time. ^-
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section 'L 5
P. O. Box 665 REC �VED APR
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone `r ' -7 Y/
1. Permit Re uested By L ha d-of h p Business Phone !27
2. Address f6 /" ocfisa%!1 < J6 CID- 4-7 - I
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 L-l",Business
IndustryOther
b) Number of people
6. a7 If house or mobile home, state size of home and number of rooms.
House Dimensions _2 d
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: Public Private Community4W,
b) Has the water supply system been approved? Yes V No
9. a) Property Dimensions A a(2 Ne_-,
b) Land area designated to building site CL
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.
Date Owne Signa ure
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.
R O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name Q � `— Date y
Address Lot Size
FACTORS AR dA;:;1 ARL AR9M-3 ARE)l !4
1) Topography/Landscape Position S S — �
PS U P�
2) Soil Texture (12-36 in.) Sandy,
Loamy, Clayey, (note 2:1 Clay)
3) Soil Structure (12-36 in.) S S
Clayey Soils �v, , PS
4) Soil Depth (inches) -4
U
5) Soil Drainage: Internal S S
PSrps
U
External S
VScUP
6) Restrictive Horizons
7) Available Space S \
U U
8) Other (Specify) S S S S
PS PS PS PS
U U
9) Site Classification S
U—UNSUITABLE S— PS— ro isionally Suita
Recommendations/Comments:
Described by �- Title Dateli
SITE DIAGRAM
�ILI
UCHO(6-82)