539 Gordon Dr !- DAVIE COUNTY HEALTH DEPARTMENT J
" IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
"NOTE: Issued in Compliance with G.S. of North Carolina Chapter 130 Article 13c
Sewage Treatment and Disosal Rules (10 NCAC 10A .1934-.1968) Permit Number
Name _\ �l x. \`, ���._��_�._ Date � �
Location \;C '�. - 5 "l�k fl �► r r , _
Subdivision Name Lot No. Sec. or Block No.
Lot Size House Mobile Home X,
� Business -Speculation _
No. Bedrooms No. Baths _ No. in Family
Garbage Disposal YES ❑ NO ❑ Specifications for System:
Auto Dish Washer YES ❑ NO ❑
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.
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Improvemen35 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.
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Final Installation Diagram: System Installed by
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Certifi ate of Compl ,tion _ 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 t
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
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/ Home Phone
1. Permit Requeste By -se ��re !,J a r dk L Business Phone
2. Address �- ��� e
3. Property Owner if Different than Above
Address
4. Permit To: a) Install ✓ Alter Re
b) Privy Conventionalpair Other Type
Ground Absorption
c) Sub-Division Sec. Lot No.,X -
5. System used to serve what type facility: House Mobile Home ✓ Business
IndustryOther
b) Number of people f
6. a) If house or mobile home, state,s'i/ze of home and number of rooms.
House Dimensions L� '� 20
Bed Rooms �]s 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 J
dishwasher ✓ sinks 3
8. a) Type water supply: Public— Private Community
b) Has the water supply system been approved? Yes NojZ
9. a) Property Dimensions I Jho K y 0 b
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.
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Date 6bwner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property: p )
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DCHD(6-82)
f l DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION Q 1
Name Date 3 V V 1
Address Lot Size add'
FACTORS AR A 1 ` AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position S S
P <It) PS PS
U U U
2) Soil Texture (12-36 in.) Sandy, S S
Loamy, Clayey, (note 2:1 Clay) S PS PS
U U U
3) Soil Structure (12-36 in.) S S S S
Clayey Soils F , � PS PS
�--(j U U U
4) Soil Depth (inches) S S
p PS PS
U U U U
5) Soil Drainage: Internal S S
p PS PS PS
U U U
External S S
PS ) PS PS
U U U
6) Restrictive Horizons
7) Available Space S S
PS P�S PS PS
U U U U
8) Other (Specify) S S S S
PS PS PS PS
U U U
9) Site Classification s
U—UNSUITABLE S—SUITABLE �Provisionaliy Suitable
Recommendations/Comments:
Described by _-�_- Title Date
SITE DIAGRAM
DCMD(6-82)