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I
' DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
R*NOTE: Issued in Compliance with G.S. of North Carolina Chapter 130 Article 13c
Sewage Treatm nt and Disposal Rules (10 NCAC 10A .1934-.1968) , Permit Number
e
Nam 'i c' , i9� i /
p Date
Location`
Subdivision Name Lot No. Sec. or Block No.
Lot Size ' House / Mobile Home Business Speculation
No. Bedrooms No. Baths 1 _ No. in Family _
Garbage Disposal YES ❑ NO--E] Specifications,for ystem--,f ,
Auto Dish Washer YES JE] NOAuto 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.
_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. or 1:00-1:30 P.M. on day of completion. Telephone Number: 704-634-5985.
Final Installation Diagram: System Installed by�"' G`
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.
1
J611 iflattilC
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT �
Davie County Health Department
Environmental Health Section IJ/�5/�5
R O. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN} ISSUED.
l Home Phone `7 / o - YY3 9
1. Permit Re ested By C\-Na-y- 1� PJ� �Q` 1 A 0.Y'�i A Business Phone
2. Address I -Sox )/0-3 oC a?00(
3. Property Owner if Different than Above
Address
4. Permit To: a) Install!!!L 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 Home" Business
IndustryOther
b) Number of people
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions-_L x k
Bed Rooms a 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 f washing machine
dishwasher sinks 1
8. a) Type water supply: Public Private Community
b) Has the water supply system been approved? Yes No Co. �tir�i4 t,v
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?
What type?
This is to certify that the informationis correct to the best of my
knowledge.
Date Owner Signature
OWNER IS SOLELY RESPONSIBLE FQR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing _
Directions to property:
0
v
DCHD(6-82)
` DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
R O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name— Date
Address Lot Size Zi�"e'
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position S S
PS PS PS
U U U
2) Soil Texture (12-36 in.) Sandy, S ,SS PS PS
Loamy, Clayey, (note 2:1 Clay) 0
U U U
3) Soil Structure (12-36 in.) S S
Clayey Soils PS PS PS
U U U
4) Soil Depth (inches) yy�� S S
S ('PSS PS PS
U U
5) Soil Drainage: Internal S S
(kS Lr% PS PS
U U U U
External S S S S
PS PS
U U U
6) Restrictive Horizons
7) Available Space S S S S
CYC � 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
Recommendations/Comments:
Described by - /4l// Title "!1 Date
SITE DIAGRAM
DCHD(6-82)