P3128 Wood ValleyVh DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*Note:. Issued in Compliance with G.S. of North Carolina Chapter 130—Article 13c.
Y J , Permit Number
-:Name�� r� e �,�, I+ Date 1'a - . b -k Z- `''s; ` 3128
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Location A, ►c M ACT–
Subdivision
T ' —
Subdivision Name rl fi Lot No. Sec. or Block No.
Lot Size 3 Er -r t c ;l House Mobile Home — ✓ Business Speculation
No. Bedrooms No. Baths a- No. in Family
Garbage Disposal YES ❑ NO ;0- j
.'� Specifications for ,System: gan �z�,Q, . `r'Fl�,L
Auto Dish Washer YES ❑ NO p ;
Auto Wash Machine YES ET. NO F-1�" 4' ?0.c� �'3 �l Z
I,
Type Water Supply
*This permit Void if sewage system described below. is not installed within 36 months from date of issue.
ik' U- til ATZ-C.
Final Installation Diagram: d_ . System ,Installed by-�g
2.
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.14
Certificate of Completion Date
The signing of this certificate shall indicate 'that the system describ d 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. it
if
a
ik' U- til ATZ-C.
Final Installation Diagram: d_ . System ,Installed by-�g
2.
�! it
.14
Certificate of Completion Date
The signing of this certificate shall indicate 'that the system describ d 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. it
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 %d( y3,'Sj
1. Permit Requested By l'4L�211 -LI,4� ch- Business Phone 76o!� 9is2�
2. Address Rn .� � l .rte
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—' -f -Business
Industry Other
b) Number of people 12
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions
Bed Rooms _6—Bath Rooms •-2- 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 D -
lavatory
dishwasher
urinals
showers
sinks
8. a) Type water supply: Public Private ---*' Community
b) Has the water supply system been approved? Yes Nom
9. a) Property Dimensions -3 /�'T o.�s
b) Land area designated to building site
c) Sewage Disposal Contractor
garbage disposal
washing machine
10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve? ^ez�
What type?
This is to certify that the information is correct to the best of my knowledge.
Date ner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WIH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
DCHD (6-82)
<1 �
DAVIL COUPTY HEALTH DEPART IEITT
ENVI.IOT MEBTAL HEALTH SECTION
SOIL/SITE EVALUATIOP
VAME C ARO (— J o H t J S tom!
ADDRESs Po - 3yc qS3
L0i'Wv►,rn1S NC 2 7oi Z
LOT SI.?E O 4c -PF,
TOPOGRAPHY:
SOIL TEZTURE: I
SOIL STRUCTURE: P5
DEPTH: S
RESTRICTIVE HOPIZOPS:
PERCOLATION PATE:
1.
2.
3.
DATE
LOCATIO14 LA Qy t N m
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Presoak Turk & time Drop Time Pate do . Inch
**CLASSIFICATIOI?: ,
SuitableProvisionally Suitable Unsuitable
CO2 i� MIT S
SAA?ITARIAIT S � S
SITE DIArPA.i
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