748 Ben Anderson Rd - DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS'PERMIT AND ,CERTIFICATE OF ._COMPLETION
"NOTE: Issued in•Compliance with•G.S.°;of North Carolina Chapter 130 Article• 136
Sewage.Treatment and Disposal Rules (10 NCAC'10A .19347,1968)':• Permit- Number '.>
Name +u. .�Y. � ' Date �-``. '5023
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Subdivision"Name. ` Lot No. Sec. or Block No.
Lot;,Size F r r '
—�_ House ' Mobile Home'_ Business Speculation
No.;Bedrooms No. Baths No. in Family
Garbage Disposal YES NO , j Specifications .for System,:.
Auto Dish Washer YES NO r
• Auto Wash Machine YES NO
.. 1 (.�r��� -�.s,,�, •:;;,`�` ". �.:"� ��`...r°�'r,
[
Type Water.Supply_. J j U ra.5
*This permit Void if sewage system described below is not installed within 36 months from,date of issue: .
it • . , I, � _ -. . t • -. . . . • •.
•.;.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.
LL
Certificate:of CompletionG Date •-5��
'The signing of.this certificate shall indicate that the system described above has been. installed incompliance;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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APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department ��30
Environmental Health Section O[l Q
P. O. Box 665 G
Mocksville, N.C. 27028 Q
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone 44 9 a w �7 G
1. Permit Requested By C . nil Business Phone
2. Address i3oti ao2 W•(• a-7d 3
3. Property Owner if Different than Above
Address
4. Permit To: a) Install I 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
Industry Other
b) Number of people a
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions 1•x ;) q
Bed Rooms -23 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 P\ 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 ( • �'1
b) Land area designated to building site
c) Sewage Disposal Contractor,14f_s 14 C1
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 �Ul nv� c �� Cin U,}D- 6'Z(1
v c.,V..
L1. 4 G:,!.�_ l � cr. "'�"f_} t�i t .'j .t'f: c)r !' �•�c ;:5 G:>� F. .`;r�` � I�_nk0
DCHD(6-82)
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DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
(^ SOIL/SITE EVALUATION
Namey o R ^P N ccs` Date r ��
Address S Lot Size
FACTORS AR A 1 AREA AREA 3 AREA 4
1) Topography/Landscape Position S S
P PS PS
U U U U
2) Soil Texture (12-36 in.) Sandy, S S
Loamy, Clayey, (note 2:1 Clay) PS PS
U U U
3) Soil Structure (12-36 in.) R'S S S
Clayey Soils p;� PS PS
U U U
4) Soil Depth (inches) S S
PS PS
U U U U
5) Soil Drainage: Internal S S S S
�j PS PS
U U U U
External S- S S
p (& PS PS
U U U
6) Restrictive Horizons
7) Available Space _ S S
pS PS PS
U U U U
8) Other (Specify) S S S S
PS PS PS PS
U U U
9) Site Classification
U—UNSUITABLE S—SUITABLE PS— ovisionally Suitable
Recommendations/Comments:
Described by Title �s�. Date L� 3
SITE DIAGRAM
G �
• a
DCHD(6-82)