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DAVIE COUNTY HEALTH DEPARTMENT
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 10A .1934-.1968) Permit Number
Name �•; �/ �� J r< - .�[. — Date by N2 l7 U
Locati n �
Subdivision Name Lot No. Sec. or Block No.
Lot Size Z42 House �--�'� Mobile Home Business Speculation
No. Bedrooms ` No. Baths c2Y,1 No. in Family !:Z
Garbage Disposal YES .0 NO 2--" Specifications for System:
Auto Dish Washer YES Q' NO 0
Auto Wash Machine YES NO
Type Water SupplyGC.!'���a
*This permit Void if sewage system d scribe e w i not installed within 36 months from date of issue.
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A
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 Z !L
I i
Certificate of Completion' < `LDate44
'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.
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section.
P. O. Box 665
Mocksville, N.C. 27028
G'(/ SOIL/SITE EVALUATION
Name Date
Address Lot Size1���G'
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position S S S
2) Soil Texture (12-36 in.) Sandy, S S S
Loamy, Clayey, (note 2:1 Clay) ,P&, US S
3) Soil Structure (12-36 in.) S S S
Clayey Soils S PS S
U
4) Soil Depth (inches) S S S
PS S
5) Soil Drainage: Internal S S S
PS c� S
External b
PS
U U
6) Restrictive Horizons `L,;2 /D e
7) Available Space S
PS PS PS S
U U U
8) Other (Specify) RC
PS PS PS S
V / U U U . �t
9) Site Classification (lam/� , S v r
U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable
Recommendations/Comments: ivc� O`S
Described by ��� Title Date A
SITE DIAGRAM
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DCHD(6-82)
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department
l Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
n Home Phone qcl g` 3 Z I E
1. Permit Requested By W , Business Phone g�3 2)5
2. Address
3. Property Owner if Different than Above
Address
4. Permit To: a) Install ✓Alter Repair
b) Privy Conventional they 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 y
6..ar If house or mobile home, state size of home and number of rooms.
House Dimensions 3 0 X to Lp
Bed Rooms Bath Rooms Z Y7— 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 urinals — garbage disposal `
lavatory showers washing machine I
dishwasher sinks S
8. a) Type water supply: Public Private Co munity
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
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 o 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:
c `
DCHD(6-82) 3
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T .
.Mn DAYIECOUNTY HEALTH DEPARTMENT q
IMPROVEMENTS 'PERMIT AND CERTIFICATE OF COMPLETION
- *NC7�E Issuetl m
1, ricewith G S 'of North Carolina ChapterA 130 Article .13c
�' Sewage Treatment and Disposal Rules (150 N,CAC`10A 1,934 1968) Y Permit: Number
Narne A' � Date ,7� l N0
;j, --
�
'
Subdivision Name L01: 0 Sec or Block No:
' LotrSize ` Hose *' Mobile Home, ` 5 Bus ess Speculation
No o Bedrooms' No Baths y /� Nin Family
�� -- 1-0�
' Garbage DisposalT- .',0, .,-,YES C-�'�"y
rSpecifications for System
Auto Dish Washer M YES,� !NO i ' r
;Auto Wash Marchine'
Type1lVater Supply � X •�
' t
This permit Void if;sewage system d scribe ` e w i not installed within 36 months from date of.'issue "
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Y l
1 1 3
3 t 4 t
I 9 t
r
r ;'Improvements permit by 1
*Contacta, representavve;of the,sgdAe _County Health Department for final inspection of this system ;between 8 30 x
9 30 A M.':or 1 00-1 30 P M on;day;of completion Telep634-5985
€ i
Final Installation Diagram E r System Instal, by
4
� 11
> Certificate of Completion Date
"The psigning of this certificate shah indicate that the system described above,.has been installed ins compliance with €
thestandards,'set forth rri.the above regulation, but shall rn NO way be taken as a guarantee"that the system:will function
satisfactorily for any given period of time 5'