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DAVIE COUNTY HEALTH-DEPARTMENT r. J
-IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
`NATE: Issu9'd .C,dmplia6ce-4th G.�/of North Caro�tna Chapter 130 Article 13c '
ewage Treatment and Disposal Rules (10 NCAC 10A .1934-.1968) Permit Number
Name ' ��s`�``Y y'/ri :S✓ L� l s- / . "DateN
0 '`
v _
Location 1/tj ,,,: a/ '�,✓.r: �t'�M rf> _
Subdivision Name Lot No. Sec. or Block No.
Lot Size House Mobile.Home _ Business Speculation
No. Bedrooms ...2No. Baths_ _ No`. in`Family
Garbage Disposal YES Cl Nb;❑ Specifications for System:
Auto Dish Washer YES ❑ NO ❑ �. ;�5�
Auto Wash Machine YES ❑ NO ❑ ��G^� ,� /
Type Water Supply _—
*This permit Void if sewage system described below is not installed within 36 months from date of issue.
i
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 ✓n
fes(
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.
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department SD
Environmental Health Section �EC
R O. Box 665
Mocksville, N.C.27028 -
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
1&r,'06191 Home Phone !00'3117,d
1. Permit Requested By yo�,oEff lA;e Business Phone /' VfyA(�,
2. Address ✓ _L G J Md /7>•t d=_
3. Property Owner if Different tha g ov D
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
IndustryOther rEidWfl�i? 107 ,
b) Number of people
6. a)If house or mobile home, state size of home and number of rooms.
House Dimensions
Bed Rooms Bath Rooms Den w/Closet _
b) If Business, Industry or Other, State: Number of persons served �y d�ED,plt
What type business, etc.
Estimate amount of waste daily (24 hours)
7. Number and type of ater-using fixtures:
commodes urinals garbage disposal
lavatory Z showers washing machine
dishwasher sinks
8. a) Type water supply: Public r/ Private Community
b) Has the water supply system been approved? Yes No
9. a) Property Dimensions
b) Land area designated to building site 'f OJN 44 6 duh / ps7A
c) Sewage Disposal Contractor
10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve? AM
Whattype?
This is to certify that the information is correct to the best of my knowledge.
./—/Y, - i�� A66��e f,
Date Owner Signature ,
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
�.�IeAlp ,fix ��esj-A I �d/,'N ss I wry
' - DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
OIL/SITE EVALUATION
6/ i �t lid
Name Date
Address Lot Size f� C
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position SS S S
(55 PS PS PS
U U U U
2) Soil Texture (12-36 in.) Sandy, S S S S
Loamy, Clayey, (note 2:1 Clay) X> PS PS PS
U U U U
3) Soil Structure (12-36 in.) S S S
Clayey Soils b PS PS PS
U U U U
4) Soil Depth (inches) S S S
PS PS PS PS
U U U
5) Soil Drainage: Internal S S S
PS PS PS
U U U
External S S S
PS PS PS
U U U U
6) Restrictive Horizons _f
7) Available Space S S S
M-
P 15 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 9PS'Provisionally Suitable
Recommendations/Comments: .197
Described byTitle Date
SITE DIAGRAM ^J
y
DCHD(6-82)