748 Fork Bixby Rd DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION j, ?
*-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
Name _ - \��._ `,\. Date _�: - d .� 4 A d
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Location ` ` kaNIN
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Subdivision Name_ Lot No. Sec. or Block No.
Lot Size,l_, House Mobile Home _ Business. Speculation
No. Bedrooms - No. Baths No. in Family r _ -
Garbage Disposal YES p NO
Specifications for System:,
Auto Dish Washer YES NO
Auto Wash Machine YES NO -p , ..
Type Water Supply
"This permit Void if sewage system described below is not installed within 36 months from date of issue.
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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.
Fi al Installation Diagram: System Installed by
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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.
i
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
1. Permit Requested By 1TAO& oUb Business Phone Pr7
2. Address L, �O �1Pct1c�E� a _e_
3. Property Owner if Different than Above `"bust�
Address (\�N a �o?z Z`16 1�21c-Y (.k11 _7CNN %C� kA-JN1Nc P N_C, ;In_M(o
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: House Mobile HomeZ Business
Industry Other
b) Number of people
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions Max&S\e \.6\Ae. C\'�\d &C. k\ol�c_-
Bed Rooms 2) 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
lavatory showers ` washing machine
dishwasher sinks 3
8. a) Type water supply: Public .zl Private Communi
b) Has the water supply system been approved? Yes-1-
9.
es N9. a) Property Dimensions �Qornu rN,-SC,
b) Land area designated to building site
c) Sewage Disposal Contractor
10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve? 't!n
What type?
This is to certify that the information is correct to the best of my knowledge.
Date Owner Signature
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)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
NameDate
Address Lot Size l
FACTORS AR A l ARCA 2 AREA 3 AREA 4
1) Topography/Landscape Position S S S
Ps (PT PS PS
U U U U
2) Soil Texture (12-36 in.) Sandy, S S
Loamy, Clayey, (note 2:1 Clay) PS PS PS
U U U U
3) Soil Structure (12-36 in.) S S
Clayey SoilsPS PS
U U U U
4) Soil Depth (inches) S S
PS PS PS
U U U
5) Soil Drainage: Internal SU S S
PS PS
U U
External S � S S
�'S� PS PS
�� U U U
6) Restrictive Horizons
7) Available Space S S S
(S PS PS
U U U
8) Other (Specify) S S S S
PS PS PS PS
U U
9) Site Classification
U—UNSUITABLE S—S vi Ily Suitable
Recommendations/Comments:
Described by Title Date _
SITE DIAGRAM
VCHO(6-82)