240 Manhattan Ln 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 ���t?£rZ: Z Ifl,r,- fr kr n Date -V82
Location 46 r+.l� �r'.S c;"Li'feS 2b, iyi2N �f r ry2
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Subdivision Name Lot No. Sec. or Block No.
Lot Size j�'� �� House `� Mobile Home _ Business Speculation
No. Bedrooms '7 No. Baths 7 No. in Family 1
Garbage Disposal YES ❑ NO [2--- , ).*
L-
Specifications ;for System: 606) �
Auto Dish Washer YES Q NO ❑ I (/
Auto Wash Machine YES [ NO -F-1700 A �
Type Water Supply �L)� 4 �- — .� -:3�x .cam -f;7^r i1F TC
`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
i
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Certificate of Complvt 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.
..0
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
4P b PS PS
U U U U
2) Soil Texture (12-36 in.) Sandy, S S S S
Loamy, Clayey, (note 2:1 Clay) (9 � US US
3) Soil Structure (12-36 in.) S S S S
Clayey Soils �j " PS PS
U U
4) Soil Depth (inches) S S S
6 PS PS
U U U U
5) Soil Drainage: Internal S^ S S S
PS PS
U U U U
External S S S
4 & PS PS
U U U U
6) Restrictive Horizons
7) Available Space S S. S S
PS PS PS PS
U U U U
8) Other (Specify) S S S S
PS PS PS PS
U Q U U U
9) Site Classification 19SI S
U—UNSUITABLE S—SUITABLE iQu II Suitable
Recommendations/Comments:
Described by Title Date
SITE DIAGRAM
DCHD(6-82)
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT q
Davie County Health Department
Environmental Health Section •
R 0. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone
1. Permit Requ stpd By
eMexl Business Phone
2. Address
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,&_'fMobile Home Business
IndustryOther
b) Number of people SZ.?
6. a) If house or mobile home, state size of home an number of rooms.
House Dimensions 'ODM��
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 Z urinalsgarbage disposal
lavatory -3 showers Z washing machine
dishwasher sinks
8. a) Type water supply: Public Private k""" Community
b) Has the water supply system been approved? Yes No
9. a) Property Dimensions /J '�1'0
b) Land area designated to building site res
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 a best of wledge.
Date wn gnature
0/
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH A STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to propel:�
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