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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 Dater ? a Z. V
Location
4
\ i
Subdivision Name -'Lot No. - Sec. or Block No.
Lot Size \ House Mobile Home _ Business Speculation
_ f
No. Bedrooms _ No. Baths "> No. in Family _
Garbage Disposal YES ❑ NO p Specifications for System:
Auto Dish Washer YES El, NO ❑
Auto Wash Machine YES 0' NO -❑
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 completion. Telephone Number: 704-634-5985. i
Final Installation Diagram: System Installed by
. F
1wc�
40
• 7
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.
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section
P. 0. Box 665 RECEIVED i u N 1 .4
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone Yta-17(/9
(/ Or,�
1. Permit Requested By T [ '- ' R Business Phone
2. Address- & _AC:
3. Property Owner if Different than Above I-o
i
Address R e. My c�E4 AIS,
4. Permit To: a) Install ✓ Alter Repair
b) Privy Conventional 'I"'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 S
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions 9"X129
Bed Rooms 3 Bath Rooms z- 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 2 urinals garbage disposal
lavatory showers 2 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 ft5!2A eze,�
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 correc to the best of my knowledge.
6 - /-1/- 09 All
Date Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
�G�R S 1tRS�
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DCHD(6-82)
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DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section,
P. O. Box 665
Mocksville, N.C. 27028
�n SOIL/SITE EVALUATION
Name-13, /I rfwrp1,� / Date 6 '/( -le
Address 1/1c kv , I Lot Size Q �-
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape PositionS S S
L� PS PS
U
U U U
2) Soil Texture (12-36 in.) Sandy, S S S
Loamy, Clayey, (note 2:1 Clay) (a cfiPS PS
U U U U
3) Soil Structure (12-36 in.) S S
Clayey Soils PS PS PS
U U U U
4) Soil Depth (inches) & P PS PS
U U U U
5) Soil Drainage: Internal SSS S S
PS PS
U U U U
External SS S
0 ��PS� 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
9) Site Classification 00, KW 5
) L -
U—UNSUITABLE S—P Tonally Suitable
Recommendations/Comments: c
Described by Title Date
SITE DIAGRAM
J
OCHD 18-82)