1160 Hwy 801N DAVIE COUNTY HEALTH DEPARTMENT `
IMPROVEMENTS PERMIT AND CERTIFICATE"OP .COMPLETION t�
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y NOTE: Issued in Compliance with G.S. of,North Carolina.Chapter 130-Article 13c
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Sewage Treatment and Disposal Rules (10 NCAC,,10A .1934-.1968) Permit Number
flame 1 l c� 7-71 C� Date . - .�C�� � J
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Location `��r, S. _ a rj'� ''ta "� ' c ..�: �� �,
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�. Subdivision Name Loti'No. Sec..or Block No. d
L,ot Size . J 06',w c,' ., House Mobile,Home ''y Business Speculation rf
NO: Bedrooms No. Baths = No. in Family ?,
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Garbage Disposal `^ YES .F NO
SpecificationsF for System:
Auto Dish Washer YES. E] NO _
Auto Wash Machine YES [Z `N0 �•
Type Water Supply 7•u --- -�
Ihis permit Void if sewage system described`below is not installed within 36' months from date of issue; r
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Improvements perm
g. it by-
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'Contact a representative of the' Davie*County' Health Department for final inspection of this system between -8:307i� 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 n,
II tl �i ii• '?
yCertificate of Completion Date � �k'7
The signing of this certificate shall. indicate that the system desdibed above has been installed in"compliance with
the" tandards set forth in the above regulation, but shall in NO way�lbe taken as a guarantee that the system will function
sati'afactorily for any given period of time:
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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.
Home Phone 9ff-
1. Permit Requested By /yi n Gene. Fosfe r Business Phone �5
A �k
2. Address -X± ��yyAdyahee , � e- 'A700' u�I � �A(Ds4 Ift
3. Property Owr�r If igerent than Above did yte►' —
Address
4. Permit To: a) Install ✓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 Homed Business
IndustryOther
b) Number of people A_
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions
Bed Rooms P2- 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 washing machine
dishwasher '-U sinks
8. a) Type water supply: Public Private—Community
b) Has the water supply system been approved? Yes No
9. a) Property Dimensions /0 o X ao d -&--
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? `R-b
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:
`fD o`� ��oL_7�
DCHD(6-82)
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DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
R 0. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
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Name �IV t cow` Date DA U�
Address Lot Size �� V
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position S S S
PS PS
U U U
2) Soil Texture (12-36 in.) Sandy, S S
Loamy, Clayey, (note 2:1 Clay) PS PS PS PS
U U U
3) Soil Structure (12-36 in.) S S S S
Clayey Soils �fp PS PS PS
�U U U
4) Soil Depth (inches) S S S
A PS PS PS
U U U U
5) Soil Drainage: Internal S S
:PS)
PS PS
U U
External S S S
p 6PS PS PS
U U U
6) Restrictive Horizons
7) Available Space S S
PS PS
U U
8) Other (Specify) S S S S
PS PS PS PS
U U
9) Site Classification
U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable
Recommendations/Comments:
Described by - Title Date
SITE DIAGRAM
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DCHD(6.92)