P3159 Robert ChunnDAVIE COUNTY HEALTH DEPARTMENT
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IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*Note: Issued n Compliance with G.S. of North Carolina Chapter 130—Article 13c.
Permit Number
Name Date i _ �'" €7o
Location
Subdivision Na
Lot Size
No. Bedrooms.
Garbage Dispc
Auto Dish Wasl
Auto Wash Mac
Type Water St
*This permit Vi
Lot No. Sec. or Block No
House ` _ Mobile Home
:2No. Baths % No. in Family.
YES p NO
Business Speculation
Specifications for System:
er YES p NO C] i
hine YES E NO 0
pply
id if sewage system described below is not installed within 36 months from date of issue
i_
Improvements permit by
*Contact a repr sentative of the Davie County Health Department for final inspection of this system between 8:30-
9:30 A.M. or 1i:00-1:30 P.M. on day of completion. Telephone Number: 704-634-5985.
Final Installation Diagram:
System Installed by
Certificate of Completion ' Date
*The signing of his certificate shall indicate that the system described above has been installed in compliance with
the standards s t forth in the above regulation, but shall in NO way be taken as a guarantee that the system will function
satisfactorily forl 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
RUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone -2,9 V - a / 7 3
1. Permit Requeste By �`'�""`� Business Phone
2. Address
3. Property Owner if Different than Above
ss
ArtrfrP-
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: Housed Mobile Home Business
IndustryOther
b) Number of people
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions
Bed Rooms — Bath Rooms— Den w/Closet
b) If Busin ss, Industry or Other, State: Number of persons served
What type business, etc.
Estimate amount of waste daily (24 hours)
7. Number a Ind type of water -using fixtures:
commodes urinals
dis
8. a) Type
b) Has t
9. a) Prop(
b) Land
c) Sewe
10. Do you
What tv
Directions to
A
showers
garbage disposal
washing machine
ashersinks
.ter supply: Public�rivate Community
water supply syste��p� been approved? YesAZNo
Dimensions
61sl
-a designated to building site
Disposal Contractor
ticipate any additions or a ansions of the facility this sewage system is intended to serve?
This is to certify that the information is correct to the best of my knowledge.
Date Owner Signature
IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
roperry:
Ae
DCHD (6-82) 1 % e
Name—
Address
GAf:T(1RC
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
R 0. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
ARFA i ARFA 9
Date
Lot Size
AREA 3 AREA 4
Topography/Land
cape Position
S
S
S
S
PS
PS
PS
PS
U
U
U
U
�) Soil Texture (12-3
in.) Sandy,
S
S
S
S
Loamy, Clayey, (n
to 2:1 Clay)
PS
PS
PS
PS
U
U
U
U
1) Soil Structure (12-36
in.)
S
S
S
S
Clayey Soils
I
PS
PS
PS
PS
U
U
U
U
g Soil Depth (inches)
S
S
S
S
PS
PS
PS
PS
U
U
U
U
i) Soil Drainage: Internal
S
S
S
S
PS
PS
PS
PS
U
U
U
U
External
S
S
S
S
PS
PS
PS
PS
U
U
U
U
1) Restrictive Horizons
Available Space
S
PS
S-
PS
S
PS
S
PS
U
U
U
U
1) Other (Specify)
S
PS
S
PS
S
PS
S
PS
U
U
U
U
1) Site Classification
U—UNSUITABLE
Recommendations/ Comments:
Described by
SITE DIAGRAM
DCHD (6-82)
S—SUITABLE PS—Provisionally Suitable
Title
Date
STATEMENT
DAVIE COUNTY HEALTH DEPARTMENT
Y_ - • - v ENVIRONMENTAL HEALTH SECTION
210 HOSPITAL STREET
P. 0. BOX 665
MOCKSVILLE, NORTH CAROLINA 27028
(704) 634-5985 /
DATE
F /��d
DETACH AND MAIL WITH YOUR CHECK. YOUR CANCELLED CHECK IS YOUR RECEIPT.
I•
BALANCE DUE -