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71,
DAVIE COUNTY HEALTH DEPARTMENT - % a 6
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 LzIz Date N2 5
r
Location
Subdivision Name Lot No. Sec. or Block No.
Lot Size Gam- House Mobile Home Business Speculation
No. Bedrooms No. Baths _ No. in Family
-Garbage Disposal YES ;p NO .[2--
Specific tion or stem:
Auto Dish Washer YES NO
Auto Wash Machine YES g NO C]
Type Water Supply
—
*This permit Void if sewage system described below isnot insl Iled within 36 months from date of•issue.
° v //"a Imp &ements jrinit by Al
*Contact a representative of the Davie County He h Depart ent for fin I inspection of this system between 8:30-,
9:30 A.M. or 1:00-1:30 P.M. on day of completi n. Teleph ne Number: 704-634-5985.
Final Installation Diagram: Jl-
tem Installed by•-
Cf-
Certificate of Completion ' Date
*The signing of this certificate shall indicate thathe 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 3
Davie County Health Department Mpy
Environmental Health Section
R O. Box 665 R�
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
/ Home Phone
1. Permit Req ted B Ae 7- i0 J./( R / Business Phone
2. Address M;�
3. Property Owner if Different than Above
Address
4. Permit To: a) Install--4- 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
b) Number of people
6. a}If house or mobile home, state size of home and number of rooms.
House Dimensions 1 '3 4 D
Bed Rooms 3 Bath Rooms d 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 0urinals garbage disposal
lavatory -a showers washing machine
dishwasher sinks
8. a) Type water supply: Public_Private Community
b) Has the water supply system been approved? Yes VINO
9. a) Property Dimensions
b) Land area designated to building site
c) Sewage Disposal Contractor
10. Do you anticipate�ny additions or expansions of the facility this sewage system is intended to serve?
What type? " G
This is to certify that the information is correct to the best of my knowledge.
Date Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
e
t to 1 /00lS
)CZ il
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DCHD(6-82)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section.
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name Date
Address Lot Size �� p
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position S
PS PS S PS
U U U U
2) Soil Texture (12-36 in.) Sandy, S S
Loamy, Clayey, (note 2:1 Clay) I> / j
U U
3) Soil Structure (12-36 in.) S S S
Clayey Soils PS tP-
4) Soil Depth (inches) S S
g PS PS PS
U U U U
5) Soil Drainage: Internal i) � S
U CUA'
External & � S
U U U
6) Restrictive Horizons
7) Available Space
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 J� _
U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable
Recommendations/Comments:
Described by /4a Title Date
SITE DIAGRAM
�i
DCHD(6-82)