963 Williams Rd (2) �..._ _
�/- / ' ► ? Polk
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 Treatment and Disposal Rules (10 NCAC 10A .1934-.1968) / Permit Number
Name
�7s✓ % �f Date 1 �r1, . . f a '2
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Location !`- �'� !� � � !r f`., ";`��/
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Subdivision Name Lot No. Seca or Block No.
Lot Size House Mobile Home _ Business Speculation
No. Bedrooms No. Baths { No. in Family
Garbage Disposal YES p NO p—
Specifications for, System:
Auto Dish Washer YES NO p >Z�
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Auto Wash Machine YES [ NO
Type Water Supply
'This permit Void if sewage system described below is not installed w(thiri 36 months from date of issue.
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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 completion. Telephone Number: 704-634-5985.
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Final Installation Diagram: tem Installed by
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7131
Certificate of Completion !"��f=f%� 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.
RECEIVED A K 2
3
y APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone �3
1. Permit Requeed By _S /_tj &/ (– N<e- Business Phone 9 g��l D U
2. Addressy����✓ /� /oT VD T
3. Property Owner if Different than Above
Address
4. Permit To: a) Install Alter Repair
b) Privy Convention alL Other Type
Ground Absorption
c) Sub-Division Sec. Lot Noj�__ _�o�.o
5. System used to serve what type facility: House Mobile Home—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 3 z
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: T
commodes urinals garbage disposal
lavatory showers washing machine
dishwasher I sinks
8. a) Type water supply: Public Privateer Community
b) Has the water supply system beep approved? Yes No
9. a) Property Dimensions— - 2 3
b) Lhnd area designated to building site Fr v-VV–
c) Sewage Disposal Contractor
10. Do you anticipate any additions'or expansions of the facility this sewage system is intended to serve? 41'0 -
What type?
This is to certify that the information is correct to the best of my knowledge.
-J
Date Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
43
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DCHD(6-82)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name_ 16/�Nell2 Date
Address Lot Size
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position S S
PS PSS PS PS
2) Soil Texture (12-36"in.) Sandy, S S S
Loamy, Clayey, (note 2:1 Clay) PS PS
U U U
3) Soil Structure (12-36 in.) S S
Clayey Soils p P PS PS
U U U U
4) Soil Depth (inches) S S S S
PS PS
--� U U
5) Soil Drainage: Internal S S S
PS PS
U U U
External SS S
PSS S PS PS
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 Dat
SITE DIAGRAM
DCMD(8-82)