122 Sonora Drive Lot 12s -1
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
Date 3�
17
Location
_ / t . , : /moi .•
Subdivision Name Lot No. Sec. or Block No.
Lot Size House Mobile Home _ Business Speculation
No. Bedrooms— No. Baths— No. in Family
—
Garbage Disposal YES ❑ NO p_-` Specifications for System:
Auto Dish Washer YES NO ❑ �/ _���,(i� .tom/.�
Auto Wash Machine YES NO ❑ CI/I
Type Water Supply
*This permit Void if sewage system described below is not installed within 36 months from date of issue.
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
L f A t(.
23-�3
Certificate of Completion _ '� Date
"The signing of this certificate shall indicate that the system describe,above has been installed in compliance with
the standards set forth in the above regulation, but shall in NO way btaken as a guarantee that the system will function
satisfactorily for any given period of time.
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APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PER' MIT
r� Davie County Health Department
Environmental health Section
P 0. Box 665
Mocksviile, N.C. 27028
WNSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
1. Permit Requested Ey ��� .:_ANdoe (-_Eiuslness Phone `M
2. Address y
3. Property Owner if Different than Above
Address
4.. Permit To: a) Install. %�Aiter Repa nr - - - -
b) Privy_— Conventional— Other Type
Ground Absorption
c) Sub -Division ___ Sec_.__.. Lot
5. System used to serve what type facility: House �d Mobile Horne E3Usi,np�gs,
IndustryOthor
b) Number of people
6. a) If house or mobile home, state size of home and number of rooms.
House- Dimensions; �/x6D
Bed Rooms_ Bath Rooms_. Den w/Closet__
b) If Business, Industry or Other, State: Number of persons served
What type business, etc.
Estimate amounf-of waste daily (24 hours) -
7. Number and type of water -using fixtures:
commodes 402' i urinals--_ garbage disposal
lavatory ^.0-7. showers—, -2- _ 4 washing machine— Z __
dishwasher sinks
8. a) Type water supply: Public_ F'rivVe Community
b) Has the water supply system been approved? Yes __�n No_—/�
9. a) Property Dimensions -
b) Land area designated to building site ✓� v_112_���8,�
c) Sewage Disposal Contractor—_- ---
10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve? /Ud�_
What type? --- '-
This is to certify that the information is correct to the best of my knowledge.
Date Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow a days for processing
Directions to property:
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Address
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DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
ARFA 9 ARFA 9
Date
Lot Size �2�5
ARFA .1 ARFA A
1) Topography/ Landscape Position
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PS
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?) Soil Texture (12-36 in.) Sandy,
Loamy, Clayey, (note 2:1 Clay)
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PS
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PS
U
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3) Soil Structure (12-36 in.)
Clayey Soils
S
S
S
PS
S
PS
U
U
U
I) Soil Depth (inches)
S
PS
PS
S
PS
S
PS
U
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i) Soil Drainage: Internal
PS
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S
PS
S
PS
U
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External�S
`PS
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PS
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PS
U
U
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i) Restrictive Horizons
Available Space
S
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PS
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PS
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1) Other (Specify)
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PS
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PS
U
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1) Site Classification
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U• S
U—UNSUITABLE S—SUITABLE PS—ProvisionallySuitable
Recommendations/Comments:
Described by _
SITE DIAGRAM
DCHD (6-82)
Title
1
Date