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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�C r r f' /'/.S'� ��'� /r�,�� �� Date T N 5751
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;. ZaVf3 el-47w 7
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Location IX' �► +' r�, ,�� ,�� - .v f
Su division Name Lot No. Sec. or Block No.
s ri('
Lot Size � House Mobile Home _Cr''s Business Speculation
No. Bedrooms No. Baths *, No. in Family_
Garbage Disposal YES ❑ NO [�J- Specifications for System:
Auto Dish Washer YES NO ❑ �QD� �� C�
Auto Wash Machine YES T__NQ ❑
Type Water Suppiy !Z/
*This permit Void if sewage system/described below is not installed within mont s from date of issue.
G
Improvements permit by
*Contact a`representative of the Davie County Health Depaqrbent for final inspection of this system between 8:30-
9:30 A.M. or 1:00-1:30 P.M. on day of, completion.�Teleph1 ne Number: 704-634-5985.
Final Installation Diagram: Sy tend Installed by
OKP
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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.
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section.
P. 0. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name ' � Date
Address Lot Size
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position SS
(0 �Pv &
U U" U
2) Soil Texture (12-36 in.) Sandy, S
Loamy, Clayey, (note 2:1 Clay) P P
3) Soil Structure (12-36 in.)
Clayey Soils
U '� bU
4) Soil Depth (inches) (& sal
PS (per
U U U
5) Soil Drainage: Internal
(� US P P
`t?
External S
U U U
6) Restrictive Horizons
7) Available Space S S S S
PS PS PS PS
U U U U
8) Other (Specify) s
S PS PS S
U U U
9) Site Classification #15 - '> -
U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable
Recommendations/Comments:
Described by %`y L/ Title Date
SITE DIAGRAM
DCHD(6.82)
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section
P. 0. Box 665
Mocksville, NC 27028.
. 1 . Application/Permit Requested By /wih/k
17,1Mailing Address �`1 (1K/G v ��iltQi . !,� �1 /
�
Home Phone `�� 'Z., S Business Phone
t
2. Name on Permit if Different than Above bpi
:3. Property Owner if Different than Above �• 1i .�/, ����C�" ��
4 . Application/Permit For : LC] General Evaluation S/Tank Installation
S. System to Serve: House V Mobile Home 0 Business
Industry C Other 0 Unknown
6. If house, mobile home: Subdivision Sec. Lot#
No. of People Dwelling Dimensions
No. of Bedrooms J Basement/Plumbing
No of Bathrooms C Basement/No Plumbing
No
Machine ,Dishwasher 0 Garbage Disposal
7 . I.f 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 : Public �rivate n Community
9 . Property Dimensions
10. Sewage Disposal Contractor
11 . Do you anticipate additions/expansions of the facility this system is
intended to serve? Yes 0 No
If yes, what type?
*NOTE: Improvements Permits shall be valid for a period of 5
�iyears from date issued. Improvements Permits are subject
H to revocation, if site plans or the intended use change.
!!' Effective October 1, 1989.
l�
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 applicatio .
D to Signat re
Directions to Property :
1�
DCHD (10-89)