P5570 Pineville Rd �.:.Y ....z.y... v:,;.:.,-�... L+''>,A aW,v.t:w ..,:� s: *< .. -s:T •<; : •. s .. t--. -- _ ..- .M .. _ .
a= •. . -4 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
"A Date
Name 4•��.,saC. � ��� t� ^� 011 L` ND "'t,l
15"70
Location \ 4
:.�\J�G..`'y�7.,` `.w �.....�.�,c:s..• , a.. � 1. �.\_,r t:. "r- \.}� �;.� ��- a.a:..' .... '.S',?.
Subdivia^ion Name Lot No. Sec. or Block No.
_�' C'!.
Lot _Size � House Mobile Home �V Business Speculation
c� t
No. Bedrooms No. Baths No. in Family
Garbage Disposal YES ❑ NO ET Specifications for System:
Auto Dish Washer YES ❑ NO p'
Auto Wash Machine YES IR� 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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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
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QC
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Certificate of Completion (► Date
*The signing of this certificate shall indicate that the system descri4d above has been in 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 vE[� MAY
P. 0. Box 665 RECD
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone 3 M
1. Permit Re sled By Business Phone
2. Address b n V� 05
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 Mobile Homelde*business
Industry Other
b) Number of people
6. a�If house or mobile home,state size of home and number of rooms.
House Dimensions 10611-114
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
8. a) Type water supply: Public Private Community_
b) Has the water supply system been approved? Yes No
9. a) Property Dimensions 3� (A IferS
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.
119 &4 aaa 4
Date Own&r Si ature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
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OCHD(6-82)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section.
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name `v Date
Address S (`� Lot Size"
FACTORS ARE 1 A ICA 2 ARE 3 ARE�.4
1) Topography/Landscape Position S _C—P5
P PS
U
2) Soil Texture (12-36 in.) Sandy, <-
Loamy, Clayey, (note 2:1 Clay) �Is—
U U U
3) Soil Structure (12-36 in.) ��s
Clayey Soils S +'S
U U U U
4) Soil Depth (inches)
5) Soil Drainage: Internal S
U U —U
External
p PS PS
U
6) Restrictive Horizons
7) Available Space
—P U U U
8) Other (Specify) S S S S
PS PS PS
9) Site Classification
U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable
Recommendations/Comments:
Cn" '%
Title Date
Described by
®-x
SITE DIAGRAM
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DCMD(6-82)