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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 .193 68
Date
. /3,T-
Location X5 X
Subdivision Name Lot No.
Permit Number
N° 5314
Sec. or Block No.
Lot Size tfe House Mobile Home _P-"' Business Speculation
No. Bedrooms _ No. Baths —Z_ No. in Family Z
Garbage Disposal YES ❑ NO 150, Specifications f r System:
Auto Dish Washer YES �} NO p
Auto Wash Machine YES [/j NO C] too-* Water Supply %n _ v�
*This permit Void if sewage system described below is not installed within 36 months from date of issue.
Improvements permit by — 6�z r �'
*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:
Jda�
System Installed by
m H
e� ve
Certi icate of Completion � - Date :),Q,\
*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.
G
APPLICATION FOR SITE EVALUATION/ IMPROVEMENTS PERMIT
Davie County Health Department a'
Environmental Health Section Q 1 3
Moc svi�lle, N.C. 7028 j REC'EI��D��
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
1. Permit Requested By
2. Address �� 664/ o / e4
3. Property Owner if Different than Above
Address
4. Permit To: a) Install ✓ Alter Repair
b) Privy Conventional Other Type
Ground Absorption
c.
Home Phone 9'98' `/a o'7
Business Phone 4O3 54' 3 `f / 6o
c) Sub -Division Sec. Lot No.
5. System used to serve what type facility: House Mobile Homey Business
IndustryOther
b) Number of people
6. ay If house or mobile home, state size of home and number of rooms.
House Dimensions _654 X 19-f
Bed Rooms -:2- 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
lavatory ✓ showers
dishwasher sinks ✓
garbage disposal
washing machine
k"
8. a) Type water supply: Public ✓ Private Community
b) Has the water supply system been approved? Yes / No ✓ �. ate, �c.e ado-s-,�. �.- 1°�s �•
9. a) Property Dimensions9-�
b) Land area designated to building site
c) Sewage Disposal Contractor A, zqe,�..
10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve? `Ire
What type?
This is to certify that the information is correct to the best of my knowledge.
/qyy Z42�� ela��
Date Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
DCHD (6-82)
e�,� = e9 A
Davie County Health Department
Environmental Health Section
Site Evaluation Consent Form
LOCATION OF PROPERTY: DATE RECEIVED
60— c � � (office use only)
yes no 1. 1 am the owner of the above described property.
yes no 2. 1 am not the owner of the above described property, however, I certify that I
have consent from , owner to obtain a
owner's name
site evaluation by the Davie County Health Department for the purpose of
determining the suitability for a ground absorption sewage treatment and
disposal system.
yes no 3. 1 hereby give consent to the authorized representative of the Davie County
Health Department to enter upon the above described property and conduct all
testing procedures as necessary to determine its suitability for a ground
absorption sewage treatment and disposal system.
DATE SIGNATURE
4. 1 hereby authorize the Davie County Health Department to release site
evaluation results from the above described property to the following:
--L-1 Owner only
— Owners designated representative
— Anyone requesting results
— Only those listed below
DATE SIGNATURE
DCHD (11 /84)
Address
FACTnRS
lz
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section.
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION �1 %
Date ! Z
Lot Size
AREA 3 AREA 4
AREA 1 AREA 2
1) Topography/ Landscape Position
d)
6)
8)
9)
S
S
S
S
S
PS
PS
PS
U
U
U
?) Soil Texture (12-36 in.) Sandy,
S
S
S
S
Loamy, Clayey, (note 2:1 Clay)
PS
PS
PS
U
U
U
i) Soil Structure (12-36 in.)
S
S
S
Clayey Soils
PS
PS
PS
U
U
U
Soil Depth (inches)
S
S
S
S
P 3
PS
PS
PS
U
U
U
U
i) Soil Drainage: Internal
S
S
S
S
p
PS
PS
PS
U
U
U
External
S
S
S
S
PS
PS
PS
U
U
U
Restrictive Horizons
Available Space
S
S
S
rpus
PS
PS
PS
U
U
U
Other (Specify)
S
S
S
S
PS
PS
PS
PS
U
U
U
U
Site Classification
U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable
Recommendations/Comments:
Described by 0� Title Xi l
SITE DIAGRAM
DCHD (6-82)
Date