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DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION -��
*NOTE: Issuel in Compliance with G.S. of North Carolina Chapter 130 Article 13c
Sewage Treatment and Disposal Rules (10 NCAC 10A .1934-.1968) Permit Number .
Name .5��, ti� � . `> ' P. INC) W Date t � - �, - + NOS, ��00
u
Location �'.� L� �� X i ��\�� .s ��`-� ; \16
1 Y>
Subdivision Name Lot No. See. or Block No.
Lot Size 1 c.'t, _ House Mobile Home _✓ Business Speculation
No. Bedrooms No. Baths No: in Family
.Garbage Disposal YES p NO Q'
Specifications for System:
Auto Dish Washer:.. YES ❑ NO
Auto Wash Machine YES NO 1 11
Type Water Supply t * .'`, _— Oce �j; t
t
*This permit Void if sewage system described below is not installed within 36 months from date of issue.
V
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 '
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
Environmental Health Section RECEIVED MAR 1
P. O. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone �►"' �Cp-
l. Permit R uested By \BusinessPhone L3 4- 35tni
2. Address S II I\/G, 70 OR ASIC hoc {�fl'I Ott 218$
3. Property Owner if Different than Above
Address
4. Permit To: a) Install ✓ Alter Repair SeP+Ic-�TRNK
b) Privy Conventional Other Type
Ground Absorption
C) Sub-Division Sec. Lot No. ro N A erg$
5. System used to serve what type facility: House Mobile Homed Business
IndustryOther
b) Number of people
6. a}If house or mobile home, state size of home and number of rooms..MO6,IR HoTW*-, bUt Not pUr QA1A&eA A4 }h;5
House Dimensions tet.. .
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 , Community
b) Has the water supply system been approved? Yes ✓ No
9. a) Property Dimensions / ACr-e.
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.
Date Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
iAKe_ (oo I �ot,cl ., �o'�n3 -6wAr8 Saal►sbLAr) 9 gg j ofrr�o
Go pbDV_jX I M;��, .�.z�;r+
�o Mba r y� o� R wile_ ;TAlexes A A;r4 RA;.4;�k AruaNs 6a\ s6r p -tb A_ Q'#
r XC 'V0)r1CX or' AN-U_ V-AvjF-v Se'A%blA Nome_
�M,.P-VQ- A4 hsn�L. �•.00 Pm. mmdotn _T nI dL q
®YL (PlU QJVIA 11_� x1111 S_Q:� UIP A +i fv t, boy swll_ e, +0 1o..e, hint,
I1J e. w:tl r�1f�i-Y. -�,.e. plfl w�,�Y�, we, would 11C� -fie- SeP��c-tRNK .
'Dow
Ue_ We- have, -Fort.
5�vaIle 'Q'I a-9— .
DCHD(6-82)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name— Date -�
1
Address �'�`�� Lot Size
FACTORS AR 1 AR 2 AR 3 AREb
1) Topography/Landscape Position S <it
S PS PS PS
U U U U
2) Soil Texture (12-36 in.) Sandy, S
Loamy, Clayey, (note 2:1 Clay) SP � A ( PS
U
U U 'Cf'
3) Soil Structure (12-36 in.)
Clayey Soils P � P
U U
4) Soil Depth (inches)
p PS PS PS
U U U
5) Soil Drainage: Internal
PS P C!�
External
PS P PS PS
6) Restrictive Horizons
7) Available Space 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 S S
U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable
Recommendations/Comments:
Described by - �- Title � '�^'� Date
SITE DIAGRAM
2
DCHD(5.82)