368 Ben Anderson Rd DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
'NOTE: Issued in Compliance with d;S. of North Carolina Chapter 130 Article 13c
Sewage Treatment and Disposal Rules (10 NCAC 10A .1934-.1.968) PermitNumber
Name �`� �r �� � �; Date �� �
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Location r :;� , .X /�,r ..U:%,/_ f -`/�'t% :;�. fes,/
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Subdivision Name Lot No. Sec. or Block No.
Lot Size House Mobile Home Business Speculation
No. Bedrooms ' No. Baths= No. in Family
Garbage Disposal YES ❑ NO Specifications for^.System: ,-
Auto Dish Washer YES NO ❑
Auto Wash Machine YES NO -❑ i
Type Water Supply i"ir _ _ fLW
'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
*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.
s f DAVIE COUNTY HEALTH DEPARTMENT
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 Date
Location
Subdivision Name Lot No. Sec. or Block No.
Lot Size House Mobile Home 1—! J Business Speculation
No. Bedrooms No. Baths _ No. in Family
Garbage Disposal YES ❑ NO p— Specifications for System:
Auto Dish Washer YES U NO
Auto Wash Machine YES [ ] NO -p
Type Water Supply _
`This permit Void if sewage system described below is not installed within 36 months from date of issue.
r
} , `✓ 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 completionVTelephone Number: 704-634-5985.
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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.
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. 0. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name c Date
Address Lot Size ,z4vlf
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position S S S S
(:'=v PS PS PS
U U U U
2) Soil Texture (12-36 in.) Sandy, S S S S
Loamy, Clayey, (note 2:1 Clay) (f�� PS PS PS
U U U
3) Soil Structure (12-36 in.) S S S S
Clayey Soils Com,' PS PS PS
U U U U
4) Soil Depth (inches) S S S S
PS PS PS
U U U
5) Soil Drainage: Internal S S S S
PS PS PS
U U U
External S S S S
PS PS PS
U U U
6) Restrictive Horizons
7) Available Space S S S
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 Date
SITE DIAGRAM
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APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section
R 0. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
• Q Home Phone ( yam s -5-r5
1. Permit Requested B i 6N 10 A u Q 4Z, Business Phone
2. Address �- a O c l U
3. yllz
Property Owner if Different than Above
Address
4. Permit To: a) Install'Alter Repair r
b) Privy Conventional Other Type
Ground Absorption
c) Sub-Division Sec. Lot No.
5. System used to serve what type facility: House Mobile Home t---Business
IndustryOther
b) Number of people
6. a) If house or mobile home, state size ofhomeand number f r oms.
House Dimensions
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 a washing machine J
dishwasher sinks
8. a) Type water supply: Public Private Community
b)
b) Has the water supply sylte`m'been approved? Yes No
9. a) Property Dimensions—
b)
4
b) Land area designated to building s'te
c) Sewage Disposal Contractor -�►� Q�
10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve? 1V(0
Whattype?
This is to certify that the information is correA to the best of my knowledge.
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3 O O
Date Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
,51 �
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DCHD(6-82)