1608 Angell Rd. ; ` �• DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION �
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*NOTE: Issued in Cr�mpliance with G.S. of North Carolina Chapter 130 Article 13c �
Sewage Treatment and Disposal Rules (10 NCAC 10A .1934-.1968) Permit Number
Name � I: _ � � { i: � ; Date - i `! ` ` . ;� �. . ;,�
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Subdivision Name Lot No. Sec. or Block No.
Lot Size ' y�� `- House � Mobile Home _ Business __ Speculation
No. Bedrooms -`> -- No. Baths _��'' ir No. in Family �=- _.
Garbage Disposal YES ❑ NO 0� Specifications for System:,�c;�'_�<..- ,,<<% •-`� �`
Auto Dish Washer YES [�] NO � -' -� �-�
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Auto Wash Machine YES � NO � ` �� � �
Type Water SuPP�Y --- -_ . � .- , ,� ;.. ..
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�This permit Void if sewage system described below is not iristalled within 36 months from date of issue.
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Improvements permit by —%'�`��'f
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"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.
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Final Installation Diagram: ._._----System-Installed by l��'j'``Z �`� �-- `'��'=�"f ��
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+ Certificate of Completi
'The signing of this certificate shall indicate that the system d
the standards set forth in the above regulation, but shall in NO �
satisfactorily for any given period of time.
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Date __
cribed above has been installed in compliance with
y be taken as a guarantee that the system will function
DAVIE COUNTY HEALTH DEPARTMENT
� • Environmental Health Section
� P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name CAIZ�-- i-E£N RY i-�urJ T � Date 3"��'� ��
/
Address p0 . abX 5'�i3 Lot Size Z�'�"'
i�1,ocIcTJ�4�c ]VC.. Z?ozb�
FACTORS
1) Topography/Landscape Position
2) Soil Texture (12-36 in.) Sandy,
Loamy, Clayey, (note 2:1 Clay)
3) Soil Structure (12-36 in.)
Clayey Soils
4) Soil Depth (inches)
5) Soil Drainage: Internal
External
6) Restrictive Horizons
7) Available Space
8) Other (Specify)
9) Site Classification
U—UNSUITABLE
Recommendations/Comments:
AREA 1
U
�
U
�
U
C�/
PS
U
�
U
S
�
�S
U
S
PS
U
P.s
S—SUITABLE
AREA 2
PS
U
S
�
�
U
PS
U
S
PS
U
�'S
S
PS
U
S
PS
U
S
PS
U
PS
U
S
PS
U
S
US
S
PS
U
S
PS
U
PS—Provisionaliy Suitable
S
PS
U
S
PS
U
S
PS
U
PS
U
S
PS
U
S
PS
U
S
PS
U
S
PS
U
Described by ��Il��y� Title ���•,�i 1Z�� Date �� ���
SITE DIAGRAM
DCHD (6-82)
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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.
1. Permit Req
2. Address —
Home Phone ��3y - 34� 1
�,,��' ��-�P_nr �tL�n� c\r. Business Phone E;.3U -5 `=i<o1
� _. ._ .... . . �. 11 _ d� i. _ _ _ _ ..
3. Property Owner if Different than Above �i � r m�r� r� T}� e) I� s I`�r c�lu.:�� r
Address �+• 4 l�o �� M��� ' c., � i j l_eT_/tI . C. _2 -�r� :� k
4. Permit To: a) Install� Alter Repair
b) Privy Conventional f 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 2 Ar�u.1�5
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 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 �
garbage disposal n o n,L
lavatory �- showers .2 washing machine �
dishwasher � sinks �
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
c) Sewage Disposal Contractor 1�l ��
10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve? N O
What type?
This is to certify that the information is correct to the best of m knowled e.
.� - E - � � �. i ^^ � -
Date wner Sign r
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
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DCHD (6-82)
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