P4956 Hwy 158"A
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DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
( ('*NOTE: Issued inCompliance with 8.S. of North Carolina Chapter 130 Article 13n
~Se,wage Treatment,Permit Number
NameDate
Location Z
Subdivision Nome Lot No. 800. or Block No
��
Lot Size Houee-_-_--__'Mobi|eHomn_-__Buain000 Speou|*tion-_--____
No. Bedrooms __4:�=-__ No. Baths No. in Family
--_-�.__-
Garbage Disposal YES [] NO p^ Specifications for System:
Auto Dish Washer YES T N(]
Auto Wash Machine
Type Water Supply
*This permit Void if sewage system descri
.tp:bbtJQtaI led within 36 months from date of issue.
--- -_- -
Improvements permit by
°Contaota representative of the Davie County Health Department for final inspection of this ayubsm between 8:30-
9:30 A.M. or 1:00'1:30 P.M. on day of completion. Telephone Number: TO4'834'5985.
Final Installation Diagram:
System Installed by
I
r
Certificate of Completion Date
*The signing of this certificate shall indicate that the system described above has been installed in compliance vidi":
the standards set forth in the above rnQu|adion, 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
I
Davie County Health Department
Environmental Health Section 1
P. O. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone
1. Permit Requested Byc1—'�L, 2/✓�L Business Phone
2. Address
3. Property Owner if Different than Above
Address
4. Permit To: a) Install Alter Repair
b) Privy Conventional 110 Other Type
Ground Absorption
c) Sub -Division Sec. Lot No.
System used to serve what type facility: House Mobile Home Business
IndustryOther
b) Number of people Z
6. a) If house or mobile home,r state size of home and number of rooms.
House Dimens'ons "J Ll�d
Bed Rooms Bath Rooms Den /Closet
b)
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 ater-using fixtures:
commodes �( urinals
lavatory showers
dishwasher n�ks
8. a) Type water supply: Public Private Com unity
b) Has the water supply system>eena pproved? Yeses No
9. a) Property Dimensions
garbage disposal
washing machine
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 corre o e best owledge.
feo—� _ k7
Date Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section.
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION ��//��
Name �Date z Il `
Address Lot Size
FAr.Tr)RC ARFA 1 ARFA 9 ARFA R ARFA A
1) Topography/ Landscape Positionbps
-A
S
PS
��
�tJ'
U
2) Soil Texture (12-36 in.) Sandy,
Loamy, Clayey, (note 2:1 Clay)
b
S
e
S
PS
S
PS
U'
6
U
3) Soil Structure (12-36 in.)
Clayey SoilsPS
S
�i'
S
PS
S
PS
U
1) Soil Depth (inches)
I/V
S
a
S
PS
i) Soil Drainage: Internal
S
PS
S
P
S
PS
U
External
S
S
(PS)
S
PS
U
i) Restrictive Horizons
A�`/9,�
Available Space
PS
S
"PS
S
PS
U
U
U
U
1) Other (Specify)
S
PS
S
PS
S
PS
S
PS
U
U
U
U
1) Site Classification
y
U—UNSUITAB —SUITABLE
PS—Provisionaliv Suitable
Recommendations/Comments:
Described by itle
SITE DIAGRAM
DCHD (5-82)
Date
6-1