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-y DAVIE COUNTY HEALTH DEPARTMENT
A
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
"NOTE: Issued in Compliance with G.S. of North Carolina Chapter 130 Article 13c
;Me,Treatment and Disposal Rules (10 NCAC 10A .1934-.1968) Permit Number
Name ' l„+�,�1 Dated
.�
Location _1cV/5,-"_i
Subdivision Name Lot No. Sec. or Block No.
Lot'Size ,/_w 11C• House Mobile Home k-- Business Speculation
No. Bedrooms No. Baths _,�— No. in Family
Garbage Disposal YES ❑ NO 8-- Specifications for System` �
Auto Dish Washe�� YES V NO ❑�
rv—
Auto Wash Machine YES NO-E]/Dv " Jc
10
Type Water Supply
----,,�'
*This permit Void if sewage system described below is not installed within 36 months from date of issue
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 J `
Environmental Health Section
R O. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
_ Home Phone
1. Permit Requested By /�06E4 7' % b00-1 /: J Business Phone
2. Address 9ou`rF V 00K / F'l - S 49,QC es,I j«le- 6zd- a7oa'1�
3. Property Owner if Different than Above SA�� X
Address
4. Permit To: a) Install v 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
IndustryOther
b) Number of people
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions 5� X q q
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 ho
7. Number and type of water -using fixtures:
commodes e_1
lavatory �--
dishwasher
urinals
showers
sinks
garbage disposal
washing machine l
8. a) Type water supply: Public Private Community
b) Has the water supply system been approved? Yes No
9. a) Property Dimensions 1:7-- Ac 2E'_
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 cgr�ectpo tI)e best of 9Ky "owledge.
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)
"C.
Address
GA (`Tn R C
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Date 1/4X
Lot Size Ave
AREA i AREA 7 AREA R ARFA A
Topography/ Landscape Position
S
S
S
S
Com'
PS
PS
PS
U
U
U
U
�) Soil Texture (12-36 in.) Sandy,
S
S
S
Loamy, Clayey, (note 2:1 Clay)
4A�
PS
PS
PS
U-
U
U
U
1) Soil Structure (12-36 in.)
S
S
S
Clayey Soils
PS
PS
PS
`tT
U
U
U
1) Soil Depth (inches)
S
S
S
PS
PS
PS
PS
U
U
U
Soil Drainage: Internal
S
S
S
S
PS
PS
PS
U
U
U
External
S
S
S
pS
PS
PS
PS
U
U
U
1) Restrictive Horizons
�.
Available Space
S
S
S
PS
PS
PS
PS
U
U
U
1) Other (Specify)
S
PS
S
PS
S
PS
S
PS
U
U
U
U
1) Site Classification
,
U—UNSUITABLE S—SUITABLE (_PS—ProvlsionallySuitable
Recommendations/ Comments: le
Described by
SITE DIAGRAM
DCHD (6-82)
Title �./ DateZZ