571 Chinquapin Rd ,._..-:_,: ',x�-�''-,.,
DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTE. issued in Compliance with G.S. of North Carolina Chapter 130 Article 13c,
Sewa a Treatment and Disposal Rules 10
� � NCA�10A�. .1934-.1968 Permit -Number
Name N_
;6 8
Location r7 `�1r .�'! ' ' /,►� ;a;il_� ✓' �� �i �� " %`.`` 1��i>X
Subdivision Name Lot No. Sec. or Block No.
Lot Size Z�2tXe' House 4.:n'— Mobile Home Business Speculation
No. Bedrooms
�.� No. Baths s No. in.Family_axl _.
Garbage Disposal YES NO [] Specifications for System:
Auto Dish Washer YES NO
Auto Wash Machine YES NO p
Type Water Supply
*This permit Void if sewage system described below is not installed within 36 months from date of issue.
f-
Improvements permit by ��C
*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: 704-63,4-5985.
Final Installation Diagram: System Installed b -
1
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Certificate of Completion ��C %(�' Date
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.
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department D Eg 2 7
Environmental Health Section
R 0. Box 665 RE
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
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Home P21
1. Permit Requ sted By �'�y -NI P✓�5� nYS�r� ►� Business Phone
2. Address f- &' . Rox 3 a 10 jsks 6_1'k
3. Property Owner if Different than Above __Tes5c S _
Address . oc u "1 , 00
/
4. Permit To: a) Install/Alter Repair Cene`Gl
b) Privy Conventional Other Type
Ground Absorption
c) Sub-Division Sec. Lot No.
5. System used to serve what type facility: House V" Mobile Home Business
I du
o? stryOther
b) Number of people ��
6. ar If house or mobile home, state size of home and number of rooms.�+,
House Dimen�sion�s� Drur;,-,-,n4fdr SOD S� a- ) Y04)(1`6-4- ir�@�i��� �
Bed Rooms 3 0"41 Bath Rooms 3or Den w/Closet
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 3 yr urinals garbage disposal
lavatory showers or y washing machine
dishwasher ) sinks
8. a) Type water supply: Public Private_l Community
b) Has the water supply system been approved? Yes No
9. a) Property Dimensions Q� Z�_ZD ,�7 qe"'s .
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? !'Id
What type?
This is to certify that the information is correct to the best of my knowledge.
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)
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DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION /
Name � Date
Address Lot Size �� t
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position S
2) Soil Texture (12-36 in.) Sandy, S S
Loamy, Clayey, (note 2:1 Clay) S
3) Soil Structure (12-36 in.)
Clayey Soils �� PS PS S
4) Soil Depth (inches) S S
ill q (P S
5) Soil Drainage: Internal S S
P .4�b S
U
External
S
6) Restrictive Horizons
7) Available Space
PS PS PS S
U U U
8) Other (Specify) S S S
PS PS PS S
U U< U
9) Site Classification ; •J, Vr
U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable
r
Recommendations/Comments:
Described by� � Title Date
SITE DIAGRAM
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X�
X
DCHD(6-82)