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DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION ~—
*NOTE: Issued in�Compliance with G.S. of North Carolina Chapter 130 Article 13c
Sewage Treatment and Disposal Rules (10 NCAC 10A .1934-.1968) Permit-Number
Date
Name -2� �.� .. €�iM3 73
Location
_ r
Subdivision Name Lot No. Sec. 6r Block No.
Lot SizeHouse Mobile Home _� Business Speculation
No. Bedrooms Y -�— No. Baths ! No. in Family
Garbage Disposal YES ❑ NO M Specifications for System:
Auto Dish Washer. YES ❑ NO ❑i
Auto Wash Machine YES Eg/ NO .❑
Type Water Supply
Off„
*This permit Void if sewage system describes-belo(ngbs n installed within 36 months from date of issue.
. J
Improvements permit by -- -
*Contact a representative of the Davie County'�balth 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 umber: 704-634-5985.
Final Installation Diagram: "N9� System I stalled byG
Y1
Certificate of Completion 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 G``V`O P
Environmental Health Section .�
P. O. Box 665 a� -
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Q I Home Phone qag-Sao S
1. Permit Requested ByL` h�� W c CRP L �P_+CR Business Phone �1la�i- gy3
2. Address (� 2 '
3. Property Owner if Different than AbQve 6 R N e
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
IndustryOther
b) Number of people-
6.
eople6. a) If house or mobile home, statesizeof home and number of rooms.
House Dimensions A, 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 1 showers washing machine
dishwasher sinks
8. a) Type water supply: Public Private—Community
b) Has the water supply system been approved? Yes No
9. a) Property Dimensions 1h
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? hla
What type?
This is to certify that the information is correct to the best of my knowledge.
Date Owner Sig ature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL ST TE AND LOCAL LAWS
Allow 5 days for processing
Directions to property: M j1
oe
( l 4 LA
y1\10F
q S
DCHD(6.82)
Davie County Health Department
r Environmental Health Section
Site Evaluation Consent Form
LOCATION OF PROPERTY: DATE RECEIVED
(office use only)
yes no 1. 1 am the owner of the above described property.
yes no 2. 1 am not the owner of the above described property, however, I certify that I
have consent from , owner to obtain a
owner's nl&ne
site evaluation by the Davie County Health Department for the purpose of
determining the suitability for a ground absorption sewage treatment and
disposal system.
yes no 3. 1 hereby give consent to the authorized representative of the Davie County
Health Department to enter upon the above described property and conduct all
testing procedures as necessary to determine its suitability for a ground
absorption sewage treatment and disposal system.
` — � . 4
DATE SfONATURE
4. 1 hereby authorize the Davie County Health Department to release site
evaluation results from the above described property to the following:
Owner only
wners designated representative
Anyone requesting results
Only those listed below l
DATE SIGNATURE
DCHD(11/84)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section,
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
(� 8
Name A 'S' \O�- °� Date y V
Address ` [a Lot Size �'fl
FACTORS AREA 1) ARE AREA 3 AREA 4
1) Topography/Landscape Position S S
PS L PS PS PS
U �� U U
2) Soil Texture (12-36'in.) Sandy, S S
Loamy, Clayey, (note 2:1 Clay) P P
PS PS
U U
3) Soil Structure (12-36 in.) S (5 I S S
Clayey Soils S `p$ PS PS
U U U U
4) Soil Depth (inches) S S S S
PS PS
U U U U
5) Soil Drainage: Internal S S S S
PS PS PS
U U U
ExternalS S S S
PS PS
U U U U
6) Restrictive Horizons
7) Available Space S S
PS PS
U U U U
8) Other (Specify) S S S S
PS - PS PS PS
U U
9) Site Classification
U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable
Recommendations/Comments: a "
Described by Title Datev
SITE DIAGRAM -
DCHD(6-82)