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F DAVIE COUNTY HEALTH DEPARTMENT ddd
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETIONy-
"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
Location �` n �,.� c r. C �
1
J, - f`:' ^!� r~•' � \ \ !.1 J 17)- 0
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77
Subl vision Name Lot No. Sec. or Block No.
Lot Sizerc_''U X I'A.L HouseMobile Home Business Speculation
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No. Bedrooms � — No. Baths No. in Family —
Garbage Disposal YES p NO 'S] Specifications_, for System:
Auto Dish Washer. YES p NO
Auto Wash Machine YES NO t tt
c,�
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.
Final Installation Dia9 ram: System Installed by ?��-�%✓
1
Certificate of Completion �9 Date 22
"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.
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APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department Ov
Environmental Health Section
P. O. Box 665 ��C,5
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone
1. Permit Requested By
Business Phone Z7- 611 7-1
2. Address Z,, G .S` �-1
3. Property Owner if Different than Above
Address
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 Home Business
Industry Other
b) Number of people
6. a) If house or mobile home, statesize of home and number of rooms.
,, l
House Dimensions I `� �l- 7 a
Bed Rooms 7— Bath Rooms Z 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 Z_ urinals ?/ garbage disposal
lavatory 71- showers 21 washing machine
dishwasher N60t<- sinks
8. a) Type water supply: Public Private Community
b) Has the water supply system been approved? Yes No
9. a) Property Dimensions &X0 /Z'JS' _;r 4-Y47 4- / Z3.5�
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?
What type?
This is to certify that the information is correct to the best of my knowledge.
J/- y-J'7 'W,/7Q�-
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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7"
DCHD(6-82)
r DAVIE COUNTY HEALTH DEPARTMENT
ENVIRONMENTAL HEALTH SECTION
SITE EVALUATION CONSENT FORM
1. Complete the form below and return to the Davie County Health Department.
2. Carefully follow the procedures as outlined in the enclosed "Information Bulletin."
NOTE: THE ABOVE MUST BE COMPLETED BEFORE A SANITARIAN WILL BE ABLE TO
BEGIN THE REQUESTED EVALUATION.
DETACH HERE AND RETURN TO: Davie County Health Department, Environmental
Health Section, P. O. Box 665, Mocksville, N.C. 27028
Davie County Health Department
Environmental Health Section
Site Evaluation Consent Form
LOCATION OF PROPERTY: DATE RECEIVED
Co'N'�` ,�i (office use only)
yes no 1. 1 am the owner of the above described property.
yes no 2. 1 am not the owner of the above described property, however, I certify that I
have consent from , owner to obtain a
owner's name
site evaluation by the Davie County Health Department for the purpose of
determining the suitability for a ground absorption sewage treatment and
disposal system. .
yes no 3. 1 hereby give consent to the authorized representative of the Davie County
Health Department to enter upon the above described property and conduct all
testing procedures as necessary to determine its suitability for a ground
absorption sewage treatment and disposal system.
DATE SIGN URE
4. 1 hereby authorize the Davie County Health Department to release site
evaluation results he above described property to the following:
wner only
— Owners designated representative
—Anyone requesting results
— Only those listed below
DATE S NATO RE
DCHD(11/84)
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DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section,
P. 0. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name IL
�nt, G �A�� "1cl(L-' S Date
Address `-� - Ste, Lot Size
FACTORS AR&1--) ARE2 AREA 3 AREA 4
1) Topography/Landscape Position S S S
PS PS
U U
2) Soil Texture (12-36 in.) Sandy, S S S
Loamy, Clayey, (note 2:1 Clay) Q-6 PS PS
U U U U
3) Soil Structure (12-36 in.) 4._� S S
Clayey Soils
fP P PS PS
U U U U
4) Soil Depth (inches) S S,---, S S
;Pg PS PS
U U U
5) Soil Drainage: Internal S S
PS PS
U U
External S S S S
OR PS PS
U U U
6) Restrictive Horizons -
.
7) Available Space SS S
� PS PS
U U U
8) Other (Specify) S S S S
PS PS PS PS
U U U
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9) Site Classification
5
U—UNSUITABLE S—SUITABLE C�Provisionally Suitable
Recommendations/Comments:
�I0 N1
Described by '�^-`"'" Title - - va: Date
SITE DIAGRAM
a�
9-
a
DCHD(6.82)