P4767 WoodlandDAVIE :COUNTY'HEALTH. DEPARTMENT"
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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;IOA .1934-.1968) Permit Number
Name Date, . i �� t > .4 7`7
Location's to 1•t�1 +r���,.< <�\4
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Subdivision'Name'� tS�`-rr�l • {� Lot No. _-_ Sec. or Block No.,
Lot Siie House •fie _ Mobile; Home _ Business Speculation
No,•Bedrooms No.•Baths:
_Q_ No. in Family
- Garbage Disposal YES ;E]'.' -
NO
f, Specifications for System:
Auto Dish Washer YES [D/ NO p
Auto Wash Machine YES ANO ,
Type Water SupplyNI
*This permit Void if sewage system described below is ,'not installed within 36 months from date of 'issue.
`� , ^ �1' t jg a
1.f [ 'rs ,' l
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
Instal latiori,D,agea i' ' System Installed by
kv
1
Certificate of Completion \ . Date
The signing of this certificate shall indicate that the system' described above- has been installed in' corhoiiance' wit h••
the standards set,forth in the above regulation, but shall in NO way be taken as.a guarantee.thatthe 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
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone 49 2 — '7 2 OS_
1. Permit Requested By /f '-eo 43 C-72sFi�i7'h`s Business Phone
2. Address /D ISJX /y7 Z ho cell'///LG &-
3. Property Owner if Different than Above
Address
4. Permit To: a) Install V Alter Repair
b) Privy Conventional V Other Type
Ground Absorption
c) Sub -Division UJO_VD�-q�Jp Sec. Lot No.
5. System used to serve what type facility: House ✓ Mobile Home Business
Industry Other
b) Number of people Z
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions Z X 7
Bed Rooms 3 Bath Rooms Z 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 3
lavatory 4
dishwasher
urinals
showers
/ sinks /
Z
8. a) Type water supply: Public ✓ Private Community
b) Has the water supply system been approved? Yes `�No
9. a) Property Dimensions
b) Land area designated to building site
garbage disposal
washing machinE
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.
Date Own r Signa ure
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
WSJ (./9�u b
00clesou C -
DCHD (6-82)
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Address
FA r ..TOR.R
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Date 5 1 � f
Lot Size
ARF A4FA 22 AREA 3 AREA 4
2)
3)
Topography/ Landscape Position S S S
c� PS PS
U U U
Soil Texture (12-36 in.) Sandy, S S S
Loamy, Clayey, (note 2:1 Clay) PS PS
U U U
Soil Structure (12-36 in.) S S
Clayey Soils PS PS
U U U U
a
5
8)
) Soil Depth (inches) S S
PS PS
U U U U
) Soil Drainage: Internal S S S
PS " S PS PS
U U U
External S S
PS PS
U
U U U
') Restrictive Horizons
Available Space S S S
<�PS PS PS
U U U
Other (Specify) S S S S
PS PS PS PS
U U
9) Site Classification
U—UNSUITABLE
Recommendations/ Comments:
S—SUITABLE PS— rovisionally Suitable
Described by Title Date
SITE DIAGRAM
DCHD (6-82)
U—UNSUITABLE
Recommendations/ Comments:
S—SUITABLE PS— rovisionally Suitable
Described by Title Date
SITE DIAGRAM
DCHD (6-82)