P5081 Lakewood Dr IX
.� DAVIE COUNTY HEALTH DEPARTMENT
.IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION; '.
OTE: Issbed in-Compliance with G.S. of North Carefina Chapter-130 Article 13c 6
-Sewage Treatment and Disposal Rulesl(1 O.NCAC. 1 OA .1934-.1.968) Permit Number . . .
Name � es Date 5081
Location J _ '�,x hl `� , . eJA ; j
Subdivision Name !
No
Lot '. Sec. or Block No.
Lot Size House Mobile Home—y Business Speculation
No.'Bedrooms No Baths _ = No. 'in.Family`_ s
Garbage Disposal.; YES. E].• NO
;I Specifications for -System:
Auto Dish'Washer." YES 0 NO �' ( ,J C)o ,
-Auto Wash Machine ,YES, p!• NO •Ej } . . tl
X
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 Diagram: ;) : System Installed by,, s\�� - �?
t: Certificate-{lof Completion Date
The sigmnglof 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
dy -.,,.
satisfactorily for any given period of time.
1
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APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT 16 eLs
Davie County Health Department
1�' .� h �U
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028 ,_^�
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
nn Home Phone 70Y-2V7
1. Permit Requested By Jon"f s !�f /C7ir Business Phone Jim r-
2.2. Address /�I-s" ill G
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 s
Industry Other
b) Number of people 22
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions G 41 _
Bed Rooms_ .�Bath Rooms �21 Den w/Close
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 Private Community P✓ 9u•,f:o
b) Has the water supply system been approved? Yes No-LZ-
9.
om9. a) Property Dimensions /, 'y 3 ac eR s
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 sery ?
What type? d-arr ;4� le
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This is to certify that the information is correc the best of my knowledg .
'23
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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DCH6(6-82)
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DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section,
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name Date
Address S' Lot Size
FACTORS AR 1 AREkP AREA 3 AREA 4
1) Topography/Landscape Position S S S
E PS PS
U U U
2) Soil Texture (12-36 in.) Sandy, S S
Loamy, Clayey, (note 2:1 Clay) C PS PS
`i U U
3) Soil Structure (12-36 in.) S S
Clayey Soils PS PS
U U U
4) Soil Depth (inches) S S S
U PS PS
U U
5) Soil Drainage: Internal S S
PS PS PS
U 1 U U
External (!
S S
PS �I35 PS PS
U U U
6) Restrictive Horizons
7) Available Space S S
PS PS PS PS
U U
8) Other (Specify) S S S S
PS PS PS PS
UC U U
9) Site Classification �J
U—UNSUITABLE S—SUITABLE PS— rovisionally Suitable
Recommendations/Comments:
Described by �� Title '� Date3
SITE DIAGRAM
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DCHD(6.82) _