P5188 Hwy 801N c•::••. 'w c .r+�-c _ -V.w�w.F'..r"O� ., ,. .:tee- 1_
DAVIE, COUNTY HEALTH DEPARTMENT
IMPROVEMENTS ,PERMIT AND CERTIFICATE 'OF COMPLETION)
- *NOTE+Ilssued in Compliance with G.S. of North }Carolina Chapter 130 Article 13c
Sewage Treatment.and Disposal Rules ;(10 NCAC'10A .1934-.1968) Permit Nu-m6er
.; Name INA Date
Location i - h ' I i
Al
'Subdivision Name Lot No. Sec. or,Block No.
Lot Size " "µ= House• 'Mobile Home _ Business' Speculation.
No. Bedrooms . _ No. Bafhs No.i in Family _
Garbage Disposal YES*.p NO 'R Specifications for System:
Auto Dish Washer. YES f�- NO p ; a
Auto Wash Machine YES ®_ NO •Q0
Type Water Supply ---
*This permit Void if sewage system.described below is not installed withini 36 months from date of issue.
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Improvements permit by `"�`''` j" `
*Contact a representative of the Davie County Health Department for final inspection of this system between 8:30--
9:30 A.U. or 1:00-1:30 P.M. on .day of completion. Telephone Number: 704-634-5985.
Final Installation Diagram: System Installed by
b A
Certificate of Completion --�!��C Date loIf
*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.
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'1 ✓'r APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT y
�1'' p Davie County Health Department �DQ� 3
V' 04 Environmental Health Section C ,v
R0. Box 665 ��
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
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Home Phone1. Permit Reque ted By1 . Business Phone
2. Address - 4
3. Property Owner if Different than Above
Address
4. Permit To: a) Installer Alter Repair
b) Privy Conventional Other Type
Ground Absorption
c) Sub-Division Sec. Lot No.
5. System used to serve what type facility: House Y'Mobile Home Business
Industry Other
b) Number of people ��'
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions_,;_'U/�..5�12
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 d1;�
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:
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DCHD(6-62)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section,
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name �AC2� S SAE % U Date
Address S �P.�cc1 Lot Size LA
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position S S
*P PS PS
U U U
2) Soil Texture (12-36 in.) Sandy, S (� S S
Loamy, Clayey, (note 2:1 Clay) P 'RSD PS PS
U U U
3) Soil Structure (12-36 in.) S S
Clayey Soils S PS PS
U U U U
4) Soil Depth (inches) S S S
PS PS
U U U U
5) Soil Drainage: Internal SS S
PS t-L) PS PS
U U U U
External S S
PS PS
U U U
6) Restrictive Horizons
7) Available SpaceS S
h S�
CPS PS
U U U U
8) Other (Specify) S S S S
PS PS PS PS
U U U
9) Site Classification S
U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable 1
Recommendations/Comments:
Described by Title a���-��'�``� Date 5 G ^ %1�1
SITE DIAGRAM
DCHD(6-82)