127 Canter Circle Lot 91D DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
* NOTE: Issued in Compliance With Article 11 of G.S. Chapter 130a
Sanitary Sewage Systems Permit Number
Name �,�Az /%/ X�/�UJ�� Date4- No 5895
Location ��iil/ r°t`G tfrj �l��.t /`rr f .Io e:57 A , i -J %/..r"'
Subdivision Name '0N 1,fly'd A/ 7g • Lot No., __ Sec. or Block No. L
Lot Size 4 House: Mobile Home — Business Speculation
No. Bedrooms No. Baths_ No. in Family
Garbage Disposal YES ❑ NO Er' Specifications for -System:
Auto .Dish Washer YES 4 NO ❑
Auto Wash Machine YES NO ❑
Type Water Supply 60.4d _
*This permit Void if sewage system described below is not installed within 5 years from date of issue.
This permit is subject to revocation if site plans or the intended use change.
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Improvements permit by
*Contact a representative of the Davie County Health Department for final
9:30 A.M. or 1:00-1:30 P.M."'on day' of" completion. Telephone Number:
Final Installation Diagram:
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System Installed by
(0',o#'«
_4_4
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ctigh of this system between 8:30-
4-5985.
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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.`,
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Improvements permit by
*Contact a representative of the Davie County Health Department for final
9:30 A.M. or 1:00-1:30 P.M."'on day' of" completion. Telephone Number:
Final Installation Diagram:
i
System Installed by
(0',o#'«
_4_4
0
ctigh of this system between 8:30-
4-5985.
t
%i
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.`,
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 Treatmentt d Di posal .Rules (10 NCAC 10A .1934-.1968) / P@r1111t Number
Name G�A�ive .� Date ;5��1��� NO 3894
Location C��/ �/���Ar
Subdivision Name Lot No. Sec. or Block No.
Lot Size House,— Mobile Home _ Business Speculation
. , No. Bedrooms No. Baths No. in Family —L�—
Garbage Disposal YES C] NO ❑ Specifications for System
Auto Dish Washer YES p NO []
Auto Wash Machine YES E] NO C] `��D ✓3X/���
Type Water Supply
*This permit Void if sewage system described below is not installed within 36 months from date of issue.
0
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
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.
Address
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Date
Lot Size
CAPTnDC ARCA 1 AREA 9 ARFA i AREA 4
2)
3)
Topography/ Landscape Position S S S S
PS <—M7 PS PS
U U U
Soil Texture (12-36 in.) Sandy, S S S S�
Loamy, Clayey, (note 2:1 Clay) < PS PS
U U U U
Soil Structure (12-36 in.) S S S S
Clayey Soils <T11T::> PS PS
U U U U
d) Soil Depth (inches) S S S S
® PS PS
U U U U
�) Soil Drainage: Internal S S S S
PS PS
U U U U
External S S
PS PS PS PS
U U U U
6) Restrictive Horizons
') Available Space S S S
PS PS
US � U U
d) Other (Specify) S S S S
PS PS PS PS
U U U
3) Site Classification .5—, D
57 1
U—UNSUITABLE
Recommendations/ Comments:
S—SUITABLE P —
Described by Title
SITE DIAGRAM
DCHD (6-82)
Date
U—UNSUITABLE
Recommendations/ Comments:
S—SUITABLE P —
Described by Title
SITE DIAGRAM
DCHD (6-82)
Date
APPLICATION FOR SITE EVALUATION/ IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section
P. 0. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone
1. Permit Requested By Pyr✓ �A�"� � Business Phone 9"- SAyy
2. Address A0, , Qt's a g(o
3. Property Owner if Different than Above
Address
4. Permit To: a) Install ✓ Alter Repair
b) Privy Conventional.- Other Type
Ground Absorption
'O�OAY r —,—A h
c) Sub -Division N�S Sec. D Lot No. Qt
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 ��� Sf°'eY
Bed Rooms * Bath Rooms Den w/Closet
b) If Business, Industry or Other, State: Number of persons served
16'
-3
.k
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 been approved? Yes sef No
9. a) Property Dimensions / %E K de �,, .'0 r X 91i '('Jr � X /SS' d i � X /Yd • Q i� �
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4A
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.
Date Own r Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
DCHD (6-82)