P5610 Candi Ln=- DAVIE COUNTY HEALTH DEPARTMENT
' IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION b
*NOTE: Issued in Compliance with G.S. of North Carolina Chapter 130 Article 13c
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Sewage Treatment and Disposal Rules (10 NCAC 10A .1934-.1968)"' Permit Num er
Name ���� S� N �. QDate (L! N2 5610
Location 0 `�,
Subdivision Name Lot No. Sec. or Block No.
Lot Size J �V-" House Mobile Home _ Business Speculation
No. Bedrooms -7 No. Baths No.'in Family
Garbage Disposal YES :❑ NO
PQ Specifications for System:
Auto Dish Washer YES ❑ ` NO o,
Auto Wash Machine YES pT NO ❑
Type Water Supply C„ • _— `�
*This permit Void if sewage system described below is not installed within 36 months from date of issue.
G
i
Improvements permit by � \`\
*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
Certificate of Completion Bate
*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.
APPLICATION FOR SITE EVALUATION/ IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section JUN O 7
P. O. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
1. Permit F
2. Address
3. Property
Address
4. Permit To: a) Install Alter Repair
b) Privy Convention alzOther Type
Ground Absorption
c) Sub -Division Sec. Lot No
5. System used to serve what type facility: House Mobile Homed Business
b) Number of people
3 IndustryOther
6. a� If house or mobile home, state size of home and number of rooms.
House Dimensions -11-1 b l� f70
Bed Rooms3_A_ 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 a urinals garbage disposal
lavatory showers washing machine
dishwasher sinks 3
8. a) Type water supply: Public Private Community
b) Has the water supply system been approved? Yes No
9. a) Property Dimensions 5
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.
Pq_
Date Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
I&V 60>
DCHD (6-82)
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DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section.
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name `�-���-'�`� Date -
Address A m Lot Size
f
FACTnRC AREA 1\ Aa ? 1 ARE� ARFCA )
I) Topography/ Landscape Position
U
U
U
?) Soil Texture (12-36 in.) Sandy,
Loamy, Clayey, (note 2:1 Clay)
C--
P�
PS
U
U
3) Soil Structure (12-36 in.)
Clayey Soils
�_--PS
` ji �'
S
�
-
U
U
U
U
I) Soil Depth (inches)
S
U
S—
U
i) Soil Drainage: Internal
PS
U
U
U
External
PS
PS
—Z�
U
U
I) Restrictive Horizons
Available Space
C—SPSSI
P� S
PS
PS
U
U
U
U
Other (Specify)
S
S
S
PS
S
PS
S
PS
) Site Classification
U—UNSUITABLE S—S
Recommendations/Comments:
Described by �� Title
SITE DIAGRAM
DCHD (6.82)
Date 4' 11,67