760 Howell Rd DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
^� *NOTE:Issued in Compliance With Article II of G.S.Chapter 130a
Sanitary Sewage Systems Permit Number.
Name `J N . �?J ,t� \ �� Date r-� '" i� ND 5853
Location
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Subdivision Name \ Lot No. Sec. or Block No.
1 .�
Lot Size ) �` `�'� House Mobile Home Business Speculation
No. Bedrooms No. Baths No. in Family
Garbage Disposal YES ❑ NO [�'" Specifications for System:
Auto Dish Washer YES ❑ NO p
Auto Wash Machine YES ® NO ❑ I (��,� c �_a, _i
'�
Type Water Supply \_a �� _ 00
*This permit Void if sewage system described below is not installed within 5 years from date of issue.
This permit is subject to revocation if site plans or the intended use change.
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- 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 Installation Diagram: System Installed by CZ-4
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Certificate of Completion � '� Date
"The signing of this certificate shall.indicate that..the system described 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.
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section vE�
P. 0. Box 665
Mockoville, NC 27028
1 . Application/Permit Requested By �Jo
Mailing Address
Home Phone ' SfD�/� Business Phone
2. Name on Permit if Different than Above
3. Property Owner if Different than Above k1PRA gh �6 !L�
4. Application/Permit For: LC) General Evaluation NS/Tank Installation
S. System to Serve: [] House Mobile Home (] Business
Industry u Other 0 Unknown
6. If house, mobile home: Subdivision Sec. Lot#
No. of People Dwelling Dimensions
No. of Bedrooms Basement/Plumbing
N,9e. of Bathrooms Basement/No Plumbing
Washing Machine Dishwasher 0 Garbage Disposal
7. If business, industry, other: Specify type
No. of People Served No. of Sinks
No. of Commodes . No. of Urinals
No. of Lavatories No. of Water Coolers
No. of Showers
8. Type of water supply: Q Public (Private Q Community
9. Property Dimensions
10. Sewage Disposal Contractor
11 . Do you anticipate additions/ex ansions of the facility this system is
intended to serve? Yes 7o
If yes, what type?
*NOTE: Improvements Permits shall be valid for a period of 5
years from date issued. Improvements Permits are subject
to revocation, if site plans or the intended use change.
Effective October 1, 1989.
This is to certify that the information provided is correct to the
best of my knowledge, and I understand I am responsible for all
charges incurred from this application.
(2la-Zr-. Ll MY'K)
Date Signature
Directions too/Property : /
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DCHD (10-89)
AOF
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section.
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION C
Name �A s �4J p� S o V) Date a [ o
Address Z C Lot Size a °a
FACTORS ARO ACEA AREA 3 A A 4)--
1)
1) Topography/Landscape Position
PS AF-
2)
�Soil Texture (12-36 in.) Sandy,
Loamy, Clayey, (note 2:1 Clay) U U
3) Soil Structure (12-36 in.) S S
Clayey Soils
U
4) Soil Depth (inches) S S S
C\QRS' C�
U U
5) Soil Drainage: Internal S
�Ps; P �,
External � S .
U
6) Restrictive Horizons --�
7) Available Space
P P
U U
8) Other (Specify) S S S S
PS PS PS PS
9) Site Classification `S
U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable
Recommendations/Comments:
Described by Title (�N~�` - - Date
SITE DIAGRAM
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Ute' W
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DCHD(8-82)