P7572 Nicole Ln -
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DAVIE COUNTY HEALTH DEPARTMENT
yI IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
NOTE:Issued in Compliance With Article 11 of G.S.Chapter 130a
Sanitary Sewage Systems Permit
Permit Number
Name —`a 1 Date ����� NO 7 5-7 2
Location
SubdivisionNameLot No. Sec. or Block No.
Lot Size House Mobile Home _T Business _— Industry
No. Bedrooms No. Baths No. in Family 3 — Public Assembly Other
Garbage Disposal YES ❑ NO Specifications for System:
Auto Dish Washer YESNO E]
Auto Wash Ma thine YES �j NO ❑ J / ��
Type Water Supplyzl
'This permit Void if sewage system described below is not installed within 5 years from d9fe of issue.
This permit is subject to revocation if site plans or the intended use change.
00
, J
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.,
1:00-1:30 P.M.or 4:30-5:00 P.M.on day of completion.Telephone Number:704-634-5985.
Final Installation Diagram: System Installed by 1-6 Y%,, e, L k-y
S-k p i
C]Wr�� yff
Y �
90
N
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
l� Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
061f��?'P/IfFTce Phone S� YS Business Phone 7D
-~- Y_ 7/,Al,,l 9�- 4'e-7
1. Permit Requested By �h�/ �� c�.0 G N� .�
2. Address flf A 13o c "11 e , �7
3. Property Owner if Different than Above L v a"5-/'0)'L
Address W,SZoiti /?e</'1 L.l-!5.
4. Permit To: a) Install Alter Repair
b) Privy Conventional Other Type
Ground Absorption 16
c) Sub-Division Sec. Lot No.
5. System used to serve what type facility: House Mobile Home Business
IndustryOther
b) Number of people
1;2-
6. a) It house or mobile home, state size of home and number of rooms.
House Dimensions /roD !a P*
Bed Rooms r 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 2 urinals garbage disposal
lavatory showers 2 washing machine
dishwasher l sinks 3
8. a) Type water supply: Public Private ✓ Community
b) Has the water supply system been approved? No tZ
9. a) Property Dimensions 17 At 9,e -
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? /yb•
What type?
This is to certify that the information is correct to the best of my knowledge.
'�_ - ? '? Aw'z4y
Date V Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property: // �� PWe
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DCHD(6-82)
M
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section.
R 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 PositionS S S
P5 & PS PS
U U U
2) Soil Texture (12-36 in.) Sandy, S S
Loamy, Clayey, (note 2:1 Clay) qPM/ PS PS
U U U
3) Soil Structure (12-36 in.) S S S
Clayey Soils fP PS PS
U U
4) Soil Depth (inches) S S
T PS PS
U U
5) Soil Drainage: Internal S S
P PS PS
U U
Externall S S
g l'Sj PS PS
U U
6) Restrictive Horizons
7) Available Space `SVS
S S
PS 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 byTitle �' Date ✓�
SITE DIAGRAM
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DCHD(6-82)
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