191 Boxwood Church Rd 40 DAVIE COUNTY HEALTH DEPARTMENT
r �U' IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
'NOTE: Issued in Compliance with G.S.of North Carolina Chapter 130 Article 13c \
Sewage Treat ent and Disposal Rules (10 NCAC 10A .1934-.1968) Permit Number
Name 2),o 'Al '% .I! /,' Date N2 5528 1
Location i . / -
Subdivision Name Lot No. Sec.or Block No. I30
Lot Size House Mobile Home_� Business Speculation
No. Bedrooms—g No. Baths �2 No. in Family
Garbage Disposal YES 0 NO .� Specifications for System:
Auto Dish Washer YES 115 NO ❑ ,
Auto Wash Machine YES fj 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 epartmint for final inspection of this system between 8:30-
9:30 A.M. or 1:00-1:30 P.M. on day of completion. elephon Number:704-634-5985.
Final Installation Diagram: System Installed b. !' �
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a�
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Certificate of Completion/j 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.
Y, 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 Treat
-��t and Disposal Rules (10 NCAC 10A .1934-.1968)` Permit Number
Name ✓ I f��1 �G �� . �/� Date N2 5528
Location
Subdivision Name Lot No. Sec. or Block No.
Lot Size House Mobile Home —� Business Speculation
No. Bedrooms — No. Baths —2— No. in Family
Garbage Disposal YES p NO Q' - �-
ASpecifications for System;
Auto Dish Washer YES NO
Auto Wash Machine YES
.-g NO C1
Type Water Supply
*This permit Void if sewage system described below is not installed within 36 months from date of issue.
f ,
Improvements permit by _1/�✓ � I
*Contact a representative of the Davie County Health Pepartmt for final inspection of this system between 8:30-
9:30 A.M. or 1:00-1:30 P.M. on day of completion. elephon Number: 704-634-5985.
Final Installation Diagram: Sys em Installed by
Certificate of CompletionWabove
Date O
"The signing of this certificate shall indicate that the system descbeen 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.
J
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department APR i 3 �39
Environmental Health Section . RECE�VED
P. O. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN TISSUED.
Home Phon.(I'1/_&
1. Permit Re este -V 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 Mobile Homej2 Business
Industry Other
b) Number of people
6. a7 If house or mobile home, state size of home and number of rooms.
House Dimensions 1`41 X 7U
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 b en approved? Yes 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?
What type?
This is to certify that the information is correct to the best of my knowledge.
92G
Date Owner ign re
OWNER IS SOLELY RESPONSIBLE FOR C PLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
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47 '
5?_CC U_-)615-ou C14
DCHD(6-82)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section.
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION J
Name Date
Address Lot Size
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position
PS PS PS PS
U U U U
2) Soil Texture (12-36 in.) Sandy,
Loamy, Clayey, (note 2:1 Clay) PS PS PS
PS
au
3) Soil Structure (12-36 in.)
Clayey Soils � PS U"
U U
4) Soil Depth (inches) S
S FS PS PS
U U U U
5) Soil Drainage: Internal S�r � C�
U
External S S S
U /*
6) Restrictive Horizons
7) Available Space S Is,PS PS S
U 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 ! Title Date
SITE DIAGRAM
DCHD(6-82)