P3895 Indian Hills DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
;N. E( Issued'in Compliance.with G.S. of North Carolina Chapter 130..Article 13c
1TS Sewage Treatment and Disposal Rules (10 NCAC 10A .1934-.1968) Permit Number
V Name Dates /<a
Location rl /✓ i /f r'
Subdivision Name Lot No. Seca or Block No.
Lot Size ' �i%'�r
_ House `"�J Mobile Home _ Business Speculation
No. Bedrooms -r No. Baths y'r` No. in Family--
.Garbage
amily _..Garbage Disposal YES ❑ NO p'
❑ Specifications for System:
Auto Dish Washer YES NO
Auto Wash Machine YES NO ❑
Type Water Supply
*This permit Void if sewage system described below is not installed within 36 months from date of issue.
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Improvements permit by cr
*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 —2/
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Certificate of Completion Dates
*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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DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. 0. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name— Date `s 1
Address Lot Size Awa
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position S S S S
C. PS PS
U U U
2) Soil Texture (12-36 in.) Sandy, ARD
S S S
Loamy, Clayey, (note 2:1 Clay) &0? PS PS
U U U U
3) Soil Structure (12-36 in.) S S S
Clayey Soils �� PS PS
U U U U
4) Soil Depth (inches) S S
PS PS
U U U
5) Soil Drainage: Internal S S S
Ap�s PS PS
U U U U
External S S S S
PS PS PS PS
U U U U
6) Restrictive Horizons
7) Available Space S S. S 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 Suitabl
Recommendations/Comments:
Described by / Title Date
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SITE DIAGRAM
DCHD(6-82)
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
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1. Permit Req ested By �w1AL�'r-A- ROCLY1�t"L Business Phone SRrn�-
2. Address
3. Property Owner if Different than Above
Address
4. Permit To: a) Install If" 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 Home Business
1-00 IndustryOther
b) Number of people 1 00
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions S �) �a01(,3 a
Bed Rooms 3 Bath Rooms a 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 1 washing machine
dishwasher 1 sinks 1
8. a) Type water supply: Public ko"' Private Community
b) Has the water supply system been approved? Yes '� No
9. a) Property Dimensions 'leg C S
b) Land area designated to building site
c) Sewage Disposal Contractor n-'(Ky Jost C f
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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