107 Boxwood Church Rd (2)1.�• DAVIE COUNTY HEALTH DEPARTMENT
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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
7
fName '' .i;f`r''"/�ii//r�1 <` Date S //._;%' `�'ti, 1
Location r — /i '"' ;'�.' - ter✓� ;l'�'�r '� -(% -- = .i •,;s.r� �� /.i f,�/; ;.-
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 ❑
Auto Dish Washer
YES
❑
NO ❑
Auto Wash Machine
YES
❑
NO -❑
Type Water Supply
Specifications for System:
(.•
This permit Void if sewage system described belowis n
Xtinstalled within 36 months from date of issue.
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1
Itrfproveme is permit by
'Contact a representative of the Davie County Health - epartm for fine inspection of this system between 8:30-
9:30 A.M. or 1:00-1:30 P.M. on day of completio Teleph ne Nu ber: 704-634-5985.
Final Installation Diagram: yste Installed by�%-r""
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Certificate of Completion Date���(/6�
"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.
i=
x RECEIVED,.',�= c 3 0
4
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 afl- 4 '*35
1. Permit Requested By WIm. a,?a Ott&,mi , Business Phone
2. Address 11UL 211 (2,0 M p 0qn�Le 0 ; C,
3. Property Owner if Different than Above
Address
4. Permit To: a) Installer 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 Homef Business
IndustryOther
b) Number of people .5
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions 24' X V
Bed Rooms —3 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 hou
7. Number and type of water -using fixtures:
commodes 9 urinals garbage disposal
lavatory 2 showers z washing machine
dishwasher / sinks
8. a) Type water supply: PublicY"Private Community
b) Has the water supply system been approved? Yes No
9. a) Property Dimensions 8 Q
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.
Y-30-194 lea:d' /? am�214 )
Date Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
6o Wd
01L 0-f�Ct etv-1 t�� PIUJ
4W --p &u) - V6 Ltt� ", )
DCHD (6-82)
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t DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. 0. Box 665
t Mocksville, N.C. 27028
j SOIL/SITE EVALUATION
Name— Date
Address Lot Size
FACTORS AREA 1 ARFA 9 ARTA 3 AREA A
1) Topography/ Landscape Position
9)
S
S
S
S
PS
PS
U .;
U
U
U
2) Soil Texture (12-36 in.) Sandy,
S
S
S
S
Loamy, Clayey, (note 2:1 Clay)
(!9�
C
PS
PS
U
U
U
U
3) Soil Structure (12-36 in.)
S
S
S
Clayey Soils
P
PS
PS
U
U
U
1) Soil Depth (inches)
S
PS
S
PS
U
U
U
U
i) Soil Drainage: Internal
�
S
ch)S
PS
PS
U
U
U
U
External
S
S
S
(,S,
rp SD
PS
PS
U
`C�
L1
U
i) Restrictive Horizons
Available Space
`SD
S
S
PS
PS
PS
PS
U
U
U
U
1) Other (Specify)
S
S
S
S
PS
PS
PS
PS
U
U
U
U
Site Classification
U—UNSUITABLE
Recommendations/Comments:
S—SUITABLE PS—Provisionally Suitable
Described by Title Dat
SITE DIAGRAM
DCHD (6.82)
STATEMENT
` DAVIE COUNTY HEALTH DEPARTMENT
ENVIRONMENTAL HEALTH SECTION
210 HOSPITAL STREET
P. 0. BOX 665
MOCKSVILLE, NORTH CAROLINA 27028
(704) 634-5985
DATE 5/12/86
Michael Owens
L
DETACH AND MAIL WITH YOUR CHECK. YOUR CANCELLED CHECK IS YOUR RECEIPT.
BALANCE DUE —