212 Bear Creek Church Rd (2)j. � ._. _ .. -- _ ..v - 'YeePo+ : I'eh rwyn a.,,pir--S•) T ; y -• r _ ... _ _ •-. - - -'.
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' IRuI'es (10 NCAC 10A .1934-.1968) Permit Number
CNN
y�Name c I Date 1,=_�
r
4 - �l
Location
Subdivision Name III Lot No Sec. or Block No..
Lot Size Nouse ii Mobile Home _ Business Speculation
No. Bedrooms -_;No. Baths _ No yin, Family_
Garbage Disposal- YES 0., NO
Specifications for Systeme _
Auto Dish Washer.. , YESp•NO.
Auto Wash Machine -YES E�/NO []
Type Water Supply
- •l t • 1 I I it '., ,
*This permit Void if sewage system descrit &..below is not installed within .36 months from. date of issue.
--------------
Improvements ermit b _� �-j.7� .
p p y
*Contact a' representative of the Davie County Health' Department for final inspection of this system between 8:30-
9:30 A.M. c, 1:00-1:30 P.M. on day of III mpletion. Telephone Number: 704-634-5985.
Final Installation Di gram ° (? (� System Installed by
' .. it •. .•-
/*
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
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
1. Permit Requested By
2. Address
Home Phone qgg p %Z %
3. Property Owner if Different than Above
Address
4. Permit To: a) Install Alter 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 Business
IndustryOther
b) Number of people
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions
Bed Rooms 3 Bath Rooms Den Den w/Closet f/
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 garbage disposal
lavatory showers washing machine
dishwasher sinks
8. a) Type water supply: Public V"" Private Community
b) Has the water supply system been approved? Yes_ZNo
9. a) Property Dimensions I (. Zc/lz ,
b) Land area designated to building site a'& e -PL azzl4/
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 U Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 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
Date y � 7
Lot Size 0 Ck,-, AAt
FAr.TOP.q ARFA 1 AREA 9 ARFA 3 APPA A
I) Topography/ Landscape Position
S
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PS
PS
PS
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U
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?) Soil Texture (12-36 in.) Sandy,
S
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Loamy, Clayey, (note 2:1 Clay)
PS
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U
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1) Soil Structure (12-36 in.)
SS
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Clayey Soils
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PS
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U
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i) Soil Depth (inches)
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U
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�) Soil Drainage: Internal
S
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11-�s-PSS
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U
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U
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External�-�--�-��--��\
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PS
PS
U
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�) Restrictive Horizons
Available Space
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PS
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U
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1) Other (Specify)
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PS
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Site Classification
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U—UNSUITABLE S—SUITABLE PS— rovisionaliy Suitable
Recommendations/Comments:
Described by \- Title �\ 0�,'W4►�'� Date �^ `
SITE DIAGRAM