132 Justin Ct Lot 9 DAVIE COUNTY HEALTH DEPARTMENT
�1 s ��'` IMPROVEMENTS PERMIT AND 'CERTIFICATE'yOF COMPLETION M
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`NOT E Issued in Compliance with G,S of North Carolina Chapter 130,'Article 13c
z , � Sewage.Treatment and Disposal.Rules (10 NCAG;IOA :1934-.'l968) Permit Number
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Location .✓�„�7 : xn�Y 9 4 r
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Subdivision'Namer��/. 1f' r' ` ,��r Y Lot"No. Sec or"Block'No.
Lot:Size`!2, 411.00i House, i' Mobile HomeBusiness Speculation
No. Bedrooms _.No._Baths No. in-Family_y - -
Garbage',Disposal _YESl] N0'� Specifications for Systerm:
Auto Dish Washer= r YES:; NO,;p
Auto Vllash.Machine YE§z'
y : � x
Type_Water Supply _
`This permit Void if sewage system described belo�s,nJot-installed within 36 months from date of issue.
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Improvements ermi b �
P P t Y '�'
'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.'70 4 634-5985.
Final Installation"Diagram: System.Installed by. -�'�'�
F-7-
Certificate of Completion - Date C `'
The signing of this certificate shall indicate-that the system described above has been. nstalled 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
1 .satisfactorily for any given period of time..
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DAVIE COUNTY HEALTH DEPARTMENT
`itI '_' i`�z 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
Name ...,,� l>/;�;/fr Mc.if ,, ., yi �. Date 2
Location ,r
Subdivision Name r/x Lot No. Sec. or Block No.
Lot Size House Mobile Home _✓� Business Speculation
No. Bedrooms — No. Baths X No. in Family �2
Garbage Disposal YES ❑ NO p'
Specifications for System:
Auto Dish Washer YES } NO ❑ il'�J( 3; �i
Auto Wash Machine YES ITl NO ❑ V�o�X.
Type Water Supply _—
*This permit Void if sewage system described below is-.not installed within 36 months from date of issue.
� i
Improvements permit bye "r%
'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 _��''
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U ° 1 ��
Certificate of Completion Date L) ` 1
*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 RECEIVE
P. 0. Box 665 t{P R 6 1%7
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone
1. Permit Requested By Gt h Oe_ F,0 Business Phone -7 K? 7937
2. Address x0091 G ems[C" < S •C
3. Property Owner if Different than Above
Address -
4. Permit To: a) Install f-Alter Repair - Cad
b) Privy Conventional `-- Other Type U0rn%
Ground Absorption 1
c) Sub-Division SreelmFutd Pw• Sec. Lot No. % 0 —S -7 Y-0
5. System used to serve what type facility: House Mobile Home -Business or-
Industry Other—
b)
ther b) Number of people � aC/C�� �� !n'lA✓l
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions
Bed Rooms 3 Bath Rooms Z 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 Z b o X 2.cua
b) Land area designated to building site
c) Sewage Disposal Contractor S ��--
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:
DCHD(6-82)
i
• 4 DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
R O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name �S'L� Date
Address Lot Size (abxoJ
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position S S
(*2 PS PS
U U U
2) Soil Texture (12-36 in.) Sandy, S S
Loamy, Clayey, (note 2:1 Clay) /' P,S9 PS PS
U U
3) Soil Structure (12-36 in.) S S S
Clayey Soils PS PS
U U
4) Soil Depth (inches) S S S
PS PS
U U
5) Soil Drainage: Internal S S
PS PS
U U U
External S S
U PS U U
6) Restrictive Horizons
7) Available Space 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 p,,- =
U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable
Recommendations/Comments:
Described by Title Date
SITE DIAGRAM
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Davie County Health Department
18_I� Environmental Health Section
P.O. Box 848
~ S„ 210 Hospital Street
Courier# : 09-40-06 1911
Mocksville, NC. 27028
Phone:(336)-753-6780 ON-SITE WASTEWATER CERTIFICATION Fax:(336)-753-1680 .
(Check One) Replacement Remodeling Reconnection
Name: y tS 1-S Phone Number • U •06 q2— (Home)
Mailing Address: VE)?— (Work)
Email Address: SVe.Ye . y a, S P, co
Detailed Directionso Site: ,el vw'�5 �1�Y y'� C 'i G'► 4'� �YC�� ? M t'�5 6}� 1 E 4
NC /y5 Vyyam Keir ""�DZtsc✓ -
Property Address: 0,41 I ZOA UUV Q. fiyli
Please Fill In The Following In�forrmation About The EXISTING Facility:
Name System Installed Under: :j�1 f1&� k CJS e a, Type Of Facility: M
Date System Installed(Month/Date/Year): ZI 7 Number Of Bedrooms: Number Of People: \ .
Is The Facility Currently Vacant? Yes/dig./ If Yes,For How Long? �.
Any Known Problems? Yes (N0 f Yes,Explain:
Please Fill In The Following Information�A"bout The NEW Facility:
Type Of Facility: Po(dkl tP X I Number Of Bedrooms: Number of People
Pool Size Garage Size: Other: -
Jlttequested By: /' fl S Date Requested: Z d 1 Z
(Signature)
For Environmental Health Office Use Only
Approved Disapproved
Comments:
1
Environmental Health Specialist Lv Date: rF/_ 7226 02
*The signing of this form by the Environmental Health S aff is in no way intended,nor should be taken as a guarantee
(extended or limited)that the.on-site wastewater system will function properly for any given period of.time.
Payment:. Cash Check Money Order # Amount:$ Date:
Paid By Received By:
Account#: Z - Invoice#: 5g33
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