718 Liberty Church Rd _ - - _- � .- - _ _ e .-- y..-w w..ryy..�N�W'./>„'��-W • ..-.�+nv..r-M/�.. •r..r ou..., .�^•;.. �... -.:. _ _.-._ .. 4
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4 DAVIE COUNTY,:HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
I; 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
Namev Date ' 4979
Location lo �� ° �1'l- a-'w".
ssl
Subdivision Name Lot No. Sec. or Block No.
Lot Size___ _ House Mobile;Home Business Speculation,
No. Bedrooms No. Baths No. in Famil
r y
Garbage Disposal YES: ❑, NO . Specifications for System
Auto Dish Washer _ YES,•p. NO 'i
Auto Wash Machine' YES NO-,E] C�< o
l 1 1 i
lb o
Type Water Supplyjl
_ 3 X
'This permit Void if sewage system described below is not installed within 36 months from date of issue.
I` 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 �s �*^
Certificate of CompletionDate 10 r �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
QQ
Davie County Health Department
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone 5/y,2-S31//
1. Permit Re nested By 8,��1 �i9r�Fs ��/� Business Phone
2. Address o Y a)OAg
3. Property Owner if Different than Above
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 Home -f-Busines
s
Industry Other
b) Number of people AMF=? IF/
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions _ /00
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 1 washing machine l
dishwasher d sinks
8. a) Type water supply: Public Private Community
b) Has the water supply system been approved? Yesy No
9. a) Property Dimensions r'�
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 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
irections to property:
AlI
d2fVE l 440 /� 1\v
���o�.s AaJsE_
DCHD(6-82)
F
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION \
Name Date
Address p` Lot Size
FACTORS AR 1 ARA 2 ARE AREA 4
1) Topography/Landscape Position S S S
6
1 PS\ PS .
2) Soil Texture (12-36 in.) Sandy, S S S
Loamy, Clayey, (note 2:1 Clay) "S <q) PS
U U
3) Soil Structure (12-36 in.) S S S
Clayey Soils <::Ek ® -0P$ PS
U U U U
4) Soil Depth (inches) S S S S
PS
U
5) Soil Drainage: Internal S S
:P�3�
PS
U
External S
PS
U
C -[J U
6) Restrictive Horizons
7) Available Space S
pS PS PS PS
U
8) Other (Specify) S S S S
PS PS PS PS
U
9) Site Classification
U—UNSUITABLE S—SUITABLE PS— rovisionally Suitable
Recommendations/Comments: �
Described by \ - Title CDate
SITE DIAGRAM
2 '
od
0
a
DCMD(6.82) /