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,^'�f IMPROVEMENTS, PERMIT AND CERTIFICATE � COMPLETIONr �~ -'
:'*NOTE: issued in Compliance with G.S. of North Carolina Chapter 130 Article 13o
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Sewage Treatment d Disposal Rules (10NCAC 10A .1934-.1968) Permit Number
17,
Name
Location
Subdivision Name Lot No. Sec. orBlock No.
Lot Size -- House -_--____' Mobile Home Business --__-_-_ Speculation
__-_-_-_
No. Bedrooms No.No. Bathu4<�__- No. in Family
Garbage Disposal YES r] NO [? Specifications.for System:
Auto Dish Washer YES NO E]
Auto Wash Machine YES NO
Tvoo Water Supply
*This permit Void ifsewage system described below is ot installed within 36 months from date of issue.
'
Improvements permit bv
*Contact a representative of the Davie County Health Department for final i c1i of this system between 8:30-
9:30 A.M. or 1:00'1:30 P.M. on day of completion. Telephone Number: 704'S34'5985.
Final Installation Diagram: System Installed by
Certificate ofCompletion Date
*The signing of this certificate shall indicate that the system described b 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.
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT '( �
Dave County Health Department
Environmental Health Section c
P. O. Box 665 Sv�+` AS
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Roy /oo lT�
Home Phone 19,ff 9- D
1. Permit Requested By > G 4 77 Business Phone
2. Address
3. Property Owner if Different than Above �.
Address
4. Permit To: a) Install Alter Repair
b) Privy Conventional_,kf"05ther Type
Ground Absorption
c) Sub-Division Sec. Lot No.
-��
5. System used to serve what type facility: House Mobile Home-2----Business
Industry Other
b) Number of people
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions X
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 7' urinals garbage disposal
lavatory 2— showers ?/ washing machine
dishwasher sinks
8. a) Type water supply: Public Private Community w Q-4-L.
b) Has the water supply system been approved? Yes No
9. a) Property Dimensions
b) Land area designated to building site AS -
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 ict to the best of my knowledge.
s co
Date Owner Signat re
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Dire property:
13 'V Pd
ti IN
DCHD(6-62) �' �� ���°4a
�,• DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
` P. O. Box 665
Mocksville, N.C. 27028
�- - SOIL/SITE-EVALUATION `
Name Date Z
Address
Lot Size ��
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position S S S
P3 PS PS PS
U U U
2) Soil Texture (12-36 in.) Sandy, S S S S
Loamy, Clayey, (note 2:1 Clay) PS PS PS
U U U
3) Soil Structure (12-36 in.) S. S S S
Clayey Soils /P PS PS PS
�--Q" U U U
4) Soil Depth (inches) S S S
�-l� PS PS PS
U U U
5) Soil Drainage: Internal S S S
PS PS PS PS
U U U
External S.^ S S S
/-.PSD PS PS PS
U U U
6) Restrictive Horizons
7) Available Space S S S S
S PS PS PS
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 „�/��Z� Date
SITE DIAGRAM
r--
DCHD(6-62)