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DAVIE COUNTY HEALTH DEPARTMENT
A 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
Namey--1 h"e cr-fir / r �' �'.'; �S�' /f `rff„ i Date --e Z 510"T
Location /.'�r,:/ s� " �.i c` ;,,✓i �' s, f! - d " ;`t /'i� %.:' .� r i,�.��
f L �. J / �" i`��✓� . �' 8-0-ecA Schad
Subdivision Name Lot No. Sec. or Block No.
Lot. Size ,1l House _ 4!'' Mobile Home _ Business __ Speculation
No -Bedrooms No..Baths _ No. in Family -�—
Garbage Disposal YES NO ❑ Specifications for System:
Auto Dish Washer' YES NO ❑ /
Auto Wash. Machine YES NO ❑1C ,'`
�✓ IG".
Type Water Supply,
*This permit Void ifsewage system described below is not installed within 36 months from date of issue.
d
APPLICATION FOR SITE EVALUATION/ IMPROVEMENTS PERMIT PQ��
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.
1. Permit Requested By P 01y'¢ u l d evS
2. Address 3 3 6
Home Phone 6 _ 72�> 15 /
1'l C Business Phone
c c kis v r r 10
'1-
3. Property Owner if Different than Above _t) °` 14A � 1
Address 5e e e kolS+ r W o 0 a k J, 1 V ^ !b
4. Permit To: a) Install v Alter Repair
b) Privy Conventional \I/- Other Type
Ground Absorption
c) Sub -Division Sec. Lot No.
5. System used to serve what type facility: House Mobile Home Business
Industry Other
b) Number of people c
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions 2>2, K I5 0
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 hours)
7. Number and type of water -using fixtures
commodes 'Z
lavatory .71
urinal
showers
garbage disposal
washing machine
dishwasher I sinks
8. a) Type water supply: Public Private Community iia v r^� CC`' Ikk
b) Has the water supply system been approved? Yes�No
9. a) Property Dimensions a3 O 3
b) Land area designated to building site _
c) Sewage Disposal Contractor 0 � l (,g
10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve? Nn
What type?
This is to certify that the information is correct to the best o my knowledge.
�47 C r
Date Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
o' 70, C_ 4
DCHD (6-82)
vt _�'Ip
13"
fl, *VA 0-.3
3 3
H-5 .0 H- 5
H-5"15
2 I -5-3
log
105
2vv r�vA�t
23 J IZ
E50 0
2-30.3
Name—
Address
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section.
R O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION /
Date
Lot Size
FAr.TC1RC AREA i AREA 7 ARFA .q AREA A
1) Topography/ Landscape Position
9)
S
S
S
PS
PS
U
U
?) Soil Texture (12-36 in.) Sandy,
S
S
Loamy, Clayey, (note 2:1 Clay)
S
(PS)1
PS
PS
��
U
U
3) Soil Structure (12-36 in.)
�,
S
S
Clayey SoilsS
PS
PS
����
U
U
I) Soil Depth (inches)
S
S
g
� PS/
PS
PS
-�
U
U
i) Soil Drainage: Internal
S
S
S
PS
PS
PS
U
U
External
S
S
S
PS
PS
PS
U
U
i) Restrictive Horizons
Available Space
S
S
PPS
PS
U
"`QQQ
U
U
Other (Specify)
S
S
S
S
PS
PS
PS
U
U
U
Site Classification
,
-
U—UNSUITABLE
Recommendations/Comments:
Described by
SITE DIAGRAM
W
DCHD (6-82)
w.W
S—SUITABLE PS—Provisionally Suitaba
Title
Date