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DAVIE COUNTY HEALTH DEPARTMENT
!, IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION r
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 KF-N Y' • 44A N E S Date -S : ' 3616
Location
Subdivision Name Lot No. Sec. or Block No,
Lot Size i House Mobile Home _ Business __ Speculation
No. Bedrooms 2 No. Baths No. in Family f —
Garbage Disposal YES J NO 2' Specifications for System: 1C)00
Auto Dish Washer YES NO p i
Auto Wash Machine YES NO p
Type Water Supply t �- --- "[`] crC O�„t:/Y F t t:_
"This permit Void if sewage system described below is not installed within 36 months from date of issue.
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�,.klf�il.c�W
Improvements permit
`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.
^tel
Final Installation Diagram: System Installed by �,y�
's
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
1 SOIL/SITE EVALUATION
Name lNmr ALLw Tl/ LS Date (0 -7y. �X
Address L729 i4AA14U8ST S?'. Lot Size
W-5. N C- S-710-7
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position S 6S A) 0
PS
U U U
2) Soil Texture (12-36 in.) Sandy, S S S S
Loamy, Clayey, (note 2:1 Clay) PS
1Tl U
3) Soil Structure (12-36 in.) S S rS�� S
Clayey Soils (7 –(M PS
U U
4) Soil Depth (inches) S S S S
PS
U
5) Soil Drainage: Internal � � � S
PS
U U U U
External � d- (ED S
PS
U 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 S S
PS PS PS PS
U U U U
9) Site Classification
U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable
Recommendations/Comments:
Described by Title s /i /kms Date b 29 )0e
SITE DIAGRAM
e
W4c`-
DCHD(6-82)
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department ��.1 y
Environmental Health Section �" Q'g�
P. O. Box 665 IT
Mocksville, N.C. 27028 be `
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
+ Home Phone -7'z, -r0 5.
1. Permit Requested By Vent Al-Len iAckne's Business Phone `777'" 1;4q9
2. Address qa9 Un,hursA- Sh: Wk h5-bh - Salem tirAk- r II0-1
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: HouseL- Mobile Home Business
IndustryOther
b) Number of people 0 r e-
6.
6. a) If house or mobile home, state size if home and number of rooms.
I
House Dimensions 3a yv�
Bed Room —Bath RoomDen w/Closet
Rooms s 1 —
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 ;Lurinals 54 garbage disposal
lavatory showers a- washing machine
dishwasher sinks Li
8. a) Type water supply: Public Private_—Community
b) Has the water supply system been approved? Yes Nom
9. a) Property Dimensions 32 l• 5 I ` Ll a-T t " 0
b) Land area designated to building site oavop coon-��'l SWU eve TOwi sKup
c) Sewage Disposal Contractor NOV ur1Aer Cph`{'t-tvC4
10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve? No
What type?
This is to certify that the information is correct to the best of my knowledge.
u q,&-Pb Cam '--t 6
Date Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing '
Directions to property: 'TUn R �C Qj ' Pt M' '; Sic, h CUrlderArjCtSS 14 MCC 14;YI 1 j�
road will `furn O ack +0 (Xvernehi' 90 '/4 mile `k-Ur rl
rdght a}' Srctn C bet+y P Otl�s reml+q) cal-rr&s -kezac.);s -fur-h
K Aro ��fi�'oh u �°Y' 10`
Q�ain end -C�'rh ��-
LO X
d �
` 'urn rtq��
old - w -CkvY
Koos p �
DCHD(6-82)
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