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I
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 �' , / /' ,f �/ Date
l
Location
Subdivision Name Lot No. Sec. or Block No.
Lot Size
House
Mobile Home _1�- Business
Speculation —
No. Bedrooms 2
No. Baths No. in Family _ Z
Garbage Disposal
YES ❑ NO ❑-,
Specifications for System:
Auto Dish Washer
YES NO ❑
�,C,>rx..- �� l� �,
Auto Wash Machine
YES NO ❑
/��
Type Water Supply
*This permit Void if sewage system described below is not installed within 36 months from date of issue.
Improvements permit by��:� i L,
*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 =f
( ( I I 11 , r,r,"
1�0 _ f3
Certificate of Completion D�te�
"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 as a guarantee that the system will function
satisfactorily for any given period of time.
4
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1
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name g,�� Date
Address Lot Size
FAr:TrIRC APPA 1 ARTA 2 AREA 3 AREA 4
e
6)
7
8
Topography/ Landscape Position /S ?� S S S
Pg PS PS
U U U
!) Soil Texture (12-36 in.) Sandy, S S
Loamy, Clayey, (note 2:1 Clay) PS PS PS PS
U
U U
1) Soil Structure (12-36 in.) S S
Clayey Soils P PS PS PS
U U U
Soil Depth (inches) S S S S
PS PS
U U U
i) Soil Drainage: Internal S S
Pg (PSS PS PS
U U
External S S S S
PS PS PS PS
U U U U
Restrictive Horizons
) Available Space S S
S PS PS PS
U U U U
) Other (Specify) S S S S
PS PS PS PS
U U U U
9) Site Classification e t 7 1
U—UNSUITABLE
Recommendations/ Comments:
Described by
SITE DIAGRAM
DCHD (6-82)
S—SUITABLE / PS—Provisionally Suitable
Title
�! r
U—UNSUITABLE
Recommendations/ Comments:
Described by
SITE DIAGRAM
DCHD (6-82)
S—SUITABLE / PS—Provisionally Suitable
Title
�! r
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. n5
Home Phone 7 "> v
1. Permit Requested By Business Phone
2. Address j,-5-
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 Homes
IndustryOther
b) Number of people
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions
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:
commodes
lavatory
urinals
showers
garbage disposal
washing machine
dishwasher sinks
8. a) Type water supply: Public Private Community
b) Has the water supply system been approved? Yes No
9. a) Property Dimensions 25JE_' Z2W(f
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 Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to prop
DCHD (6-82)