671 Will Boone Rd (2) -: - DAVIE COUNTY HEALTH DEPARTMENT
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„i IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTEIIssued in Compliance with G.S. of North Carolina Chapter 130 Article 13c
Sewage Treatment andrDisposal Rules (10 NCAC 10A .1934-.1968) Permit Number
Name :s "� p� c� _fit Date ND 5
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Location
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Subdivision Name Lot No. Sec. or Block No.
Lot Size r ` r� 'szi House Mobile Home _� Business Speculation
No. Bedrooms No. Baths'. No. in Family
Garbage Disposal YES Cl. NO [ Specifications for.System: f
Auto Dish Washer YES p NO
Auto Wash Machine' . YES ❑ NO -p �, y
Type Water Supply
*This per ' Void if sewage system described below is not installed within•36'months from date of issue.
�\y`1 i
ol
co
w
,I pro eme is permit by
i'
*Contact a representative of the Davie County Health DeparlMentAor 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
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.
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT `
Davie County Health Department HQV
Environmental Health Section
P. O. Box Ess RE�Ew
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone-
1.
hone 1. Permit Reque ted B Business Phone
2. Address ► 2.76 G
-,3. Property Owner if Different.than Above
Address
4. Permit To: a) Install-ZAlter 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 Bs
Industry Other
b) Number of people
6. a)If house or mobile home, slate size of home and number of rooms.
House Dimensions X V
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 ,n, garbage disposal
lavatory showers washing machine I
dishwasher / sinks `
8. a) Type water supply: Public Private Community -
b) Has the water supply system been approved? Yes-t4'_No
9. a) Property Dimensions Q 1L
b) Land area designated to building site C"S
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 k owl edge.
Date Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND L CAL.LAnWS
Ad /'d��,A��1
Allow 5 �for���ces�gY� �i1��1 Cf � !�/-/1'��I'� oYt �C 7L
Directions to property: �``
*NOTE: Improvements Permits shall be valid for a period of 5 . I
+ years from date issued. Improvements Permits are subject
'i
( to revocation, if site plans or the intended use change.
Effective October 1, 1989.
DCHD(6-82)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section.
R 0. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION Q
Name U TVY� t'S b Date
Address ,S'A rd` .Q Lot Size
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position S < S S
2) Soil Texture (12-36 in.) Sandy, S S
Loamy, Clayey, (note 2:1 Clay)
3) Soil Structure (12-36 in.) S
Clayey Soils PS �
U
U
4) Soil Depth (inches)
PS P�
U U
5) Soil Drainage: Internal S
b'
External S
PS
U U U
6) Restrictive Horizons
7) Available Space S S S
PS PS
U U U U
8) Other (Specify) S S S S
PS PS PS PS
9) Site Classification SV�A
U—UNSUITABLE S—SUITA \ PS—Provisionally Suitable
,` , (�
Recommendations/Comments: ��
Described by �• Title Date
SITE DIAGRAM
DCHD(6-82)