4234 Hwy 601S (3) DAVIE COUNTY HEALTH DEPARTMENT
"i 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
Namel%^ dl� �,�r_ > -` Y Date s``� c• �R s ,''
Location
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Subdivision Name Lot No. Seca or Block No.
Lot Size =; House Mobile Home Business Speculation
No. Bedrooms _ No. Baths _ _ No. in Family _
Garbage Disposal YES Ej NO [2' Specifications for System:
Auto Dish Washer YES NO �G,G} ,✓j .
Auto Wash Machine YES NO '` '``'
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 ✓� � �'a ` J �'(
I ;
Certificate of Completion' Date
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*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. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name Date
Address Lot Size ��
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position ��, S S
( PS's SPS PS PS
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.) .8�,,� S S
Clayey Soils '-0J PS PS
U U U
4) Soil Depth (inches) S S
PS PS PS
U U
5) Soil Drainage: Internal S S
p PS PS
U U
External S S
pg PS PS
U U
6) Restrictive Horizons
7) Available Space
as S S S
S 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
JoirAll–
SITE DIAGRAM
DCHD(8-82)
1 r . REC
. PPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERM6E AEv AU
Davie.County Health Department G
Environmental Health Section 'fib
P. 0. Box 665
Mocksville, N.C. 27028
�bNSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
t�Home Phone
1. Permit Req ,ue ed By Ono,�� j 6Y\ n Ar('. f d7i Business Phone
2. Address o
3. Property Owner if Different than Above cl- e e YhU
Address �� o
4. Permit To: a) Install_LfAlter Repair
b) Privy Conventional Other Type
Ground Absorption
1 -
c) Sub-Division Sec. Lot No.
5. System used to serve what type facility: House - Mobile Home_l�_Business
Industry Other
b) Number of people .�
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions / '/ X �'?
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 washing machine
dishwasher sinks 3
8. a) Type water supply: Public Private Community
b) Has the water supply system been approved? Yes �No
9. a) Property Dimensions P�S
b) Land area designated to building ' e Pr er" __II
c) Sewage Disposal Contractor )v�p Sg4T Ir An
10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve? Or) �
What type?
This is to certify that the information is corre to
the best of my knowledge.
'Z Z Z'5_::�
Date Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
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DCHD(6-82)