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DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTE: Issued in Compliance with G.S. of North Carolina Chapter 130 Article 13c
Sewa a Treatment and Disposal Rules (10 NCAC 10A .1934-.1968) Permit Number
Name �i F ,c'��r:i' �..�j %?; t' Date _� <i AS 17 i fa
�
Location
G �T
Subdivision Name Lot No. Sec. or Block No.
Lot Size IV House Mobile Home _�-� Business Speculation
No. Bedrooms - -cam— No. Baths mJ No. in Family 9 —
Garbage Disposal YES ❑ NO Specifications for System:
Auto Dish Washer YES, NO ❑ ,�:.`->>�/
Auto Wash Machine YES $ O ❑
Type Water Supply
*This permit Void if sewage system described below is not installed within 36 months from date of issue.
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
r_
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
�9y
0NSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone
1. Permit Req u to By Business Phone
2. Address �
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_te:!::� Business
Industry Other
b) Number of people 1:2-
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions__Z X 76
Bed Rooms 2Z 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 urinals
lavatory o2 showers
dishwasher sinks i
8. a) Type water supply: Public Privatey Community
b) Has the water supply syste/n been approved? YeS�NO
9. a) Property Dimensions ��
b) Land area designated to building site
c) Sewage Disposal Contractor
garbage disposal
washing machine l
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 knowledg
Date Owne ignature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
9a 7t
CAO
DCHD (6-82)
Address
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Date
Lot Size
FArTnR.R AREA 1 AREA 2 AREA 3 AREA 4
Topography/ Landscape Position
9)
S
S
S
PS
PS
PS
`—�
U
U
U
!) Soil Texture (12-36 in.) Sandy,
S
S
S
Loamy, Clayey, (note 2:1 Clay)
/( PSJ
PS
PS
PS
U
U
U
1) Soil Structure (12-36 in.)
S
S
S
Clayey Soils
PS
PS
PS
U
U
U
1) Soil Depth (inches)
S
S
S
PS
PS
PS
U
U
U
Soil Drainage: Internal
S
S
S
PS
PS
PS
U
U
U
External
S
S
S
PS
PS
PS
PS
U
U
U
�) Restrictive Horizons
Available Space
S
S
S
PS
PS
PS
U
U
U
1) Other (Specify)
S
PS
S
PS
S
PS
S
PS
U
U
U
U
Site Classification
U—t
Recommendations/Comments:
Described by _
SITE DIAGRAM
DCHD (6-82)
S—SUITABLE PS—Provisionally Suitable
® �/ _ r --
Title '>WAII Date 6l19�