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A/ t DAVIE COUNTY`HEALTH DEPARTMENT
r 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 Date '
Location ! - �' _ -i, %' ili ,-` / l ` _ •
Subdivision Name Lot No. Sec. or Block No.
Lot Size % House Mobile Home Business Speculation
No. Bedrooms _ No. Baths No. in Family
Garbage Disposal YES .E] NO 8 Specifications for System:
Auto Dish Washer YES NO p �
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.
! .
Improvements permit by %/X
*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. on day of completion. Telephone Number: 704-634-5985.
Final Installation Diagram: System Installed by
Ir
ba
ick' afi e of—Completion *%
*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.
_ Dw
` APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department I
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone 492--1(P9
1. Permit Requested By DAVID To 1'?1C.1._O2 Business Phone
2. Address
3. Property Owner if Different than Above PoLaJE'L_L_
Address
4. Permit To: a) Install�Alter Repair—1
b) Privy Conventional 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 4-
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions
3
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 Lr' /No
9. a) Property Dimensions
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? ?a5 =-�
What type?
This is to certify that the information is correct to the best of my knowledge.
Date Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
fo
, I
DCHD(6-82)
1
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 S
C PS PS PS
U U U U
2) Soil Texture (12-36 in.) Sandy, S S S
Loamy, Clayey, (note 2:1 Clay) /,PS '� PS PS PS
U U U
3) Soil Structure (12-36 in.) S S S
Clayey Soils PS PS PS PS
U U U
4) Soil Depth (inches) S S S
PS PS PS
\ U U U
5) Soil Drainage: Internal S S S
PS PS PS
U U U U
External. S S S
PS PS PS
U U U U
6) Restrictive Horizons
7) Available Space S S S S
PS PS PS
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
s--
Recommendations/Comments:
Described byj Title Date
SITE DIAGRAM 1Q
4k)
DCHD(6-82) "�
�tti�iP (1�6nn#� �ettl#� �e�ttr#men#
Mnb Fame Health Agenrg
P' 0* BOX 665
gorkoille, North Carolina 27628
OFFICE OF THE DIRECTOR October 24, 1986 TELEPHONE
(7041 634.5985
Mr. David T. Miller
Route 1, Box 60-22
Mocksville, NC 27028
Mr. Miller:
As per your request a representative from this office visited your site
on October 24, 1986 in order to determine the soil/site suitability for the
installation of a ground absorption sewage system. Unfortunately, due to the
following reason we were unable to conduct the evaluation. - Please notify
this office as soon as the item or items below have been completed. Upon noti-
fication, this office will place your application back in the active file and
again be placed on our work schedule. Nothing was staked off at the site.
Sincerely,
Robert . Hall, Jr. R. S.
Environmental Health
RBHJR:sg