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DAVIE COUNTY HEALTH DEPARTMENT I
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IMPROVEMENTS PERMIT AND CERTIFICATE-OF COMPLETION
*NOTE: Issu"6d 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 ` o ��, � .`� 1; t' �! _ Date
Location
Subdivision Name Lot No. Sec. or Block No.
Lot Size ,^j _4 House Mobile Home — Business Speculation
No. Bedrooms No. Baths —� No. in Family n —
Garbage Disposal YES [Z/ NO ❑ Specifications for System:
Auto Dish Washer. YES ❑p' NO ❑ - -'"
Auto Wash Machine YES p, NO ❑
Type Water Supply
*This permit Void if sewage system described below is not installe0 within 36 months from date of issue.
X a
YJO
IM
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a
Improvements permit by —
*Contact a representative c the D ounty Health Department for final inspection of this system between 8:30-
9:30 A.M. or 1:00-1:30 P.A. on Fay bf-completion. Telephone Number: 704-634-5985.�=��
Final Installation Diagram: System Installed by �-
&
J`
Certificate of Completion !?`f�,j✓ 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
;�0 Davie County Health Department PQ
Environmental Health Section !Q
R O. Box 665
Mocksville, N.C. 27028
4
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
,{ Home Phone
1. Permit Requested By_ Q _� s t re V e Business Phone /'3627
2. Address /d'3 rj
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 15rtXlwf F{./ft Sec. Lot No.
5. System used to serve what type facility: Housed Mobile Home Business 0
Industry Other
b) Number of people Z
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions 7.2 ,'a 8' rAuc�
Bed Rooms_3 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 3 urinals garbage disposal
lavatory 3 showers 3 washing machine
dishwasher sinks l
8. a) Type water supply: Public Private—X—Community
b) Has the water supply system been approved? Yes Nom
9. a) Property Dimensions 90 OfX r
b) Land area designated to building site A&hre%x'. q Acrer
C) Sewage Disposal Contractor Je r -v
10. Do you anticipate any additions or expan ions of the facility this sewage system is intended to serve? n.
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)
Davie County Health Department
Environmental Health Section
r`
Site Evaluation Consent Form
LOCATION OF PRO ERTY: DATE RECEIVED
,Mct 7-ewu sl,P (office use only)
�/
r A74 r1V1 j
ye 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 name
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.
DATE SIGNATURE
4. 1 hereby authorize the Davie County Health Department to release site
evaluation results from the above described property to the following:
Owner only
Owners designated representative
Anyone requesting results
Only those listed below
DATE SIGNATURE
DCHD(11/84)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
- SOIL/SITE EVALUATION
Name �`c�s � nsi�r�l Date
Address Lot Size 1
FACTORS AR 1 ARA 2 ARE 3 AREA 4
1) Topography/Landscape Position S S S S
C (TED PS PS
U U U U
2) Soil Texture (12-36 in.) Sandy, S S
Loamy, Clayey, (note 2:1 Clay) P AP ct) PS
U U U
3) Soil Structure (12-36 in.) S S S
Clayey Soils <PS <1 PS
�-' U U U
4) Soil Depth (inches) (Ss � S
PS
U U U U
5) Soil Drainage: Internal S S
PS P PS PS
U U
External S S S S
PS PS PS PS
U U U U
6) Restrictive Horizons
7) Available Space CD S
PS 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
U—UNSUITABLE S—SUITABLE PS Provisionally Suitable
Recommendations/Comments:
Described by �' Title -L Date �7 "6
SITE DIAGRAM
DCMD(6-82)