145 Feed Mill Rd _ DAVIE COUNTY HEALTH DEPARTMENT
. IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTE: |onuod inCompliance with G.G. of North Carolina Chapter 130 Article 13o
Sewage Treatment and Disposal Rules (10 NCAC 10A .1034-.1968) Permit Number
Name Date
Location
Subdivision Name Lot No. Seo or Block No
Lot Size House Mobile Home Business -- Speculation
No. Bedrooms No. Baths No. in Family
Garbage Disposal YES NO 2— Specifications for System;.,'
Auto Dish Washer YES NO []
Auto Wash Machine YES NO
Type Water Supply^
*This permit Void if sewage system described below is not-instalre--d-within 36 months from date of issue.
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Improvements permit, bv
*Contact a representativeo[ the Davie County Health Dppartment for final inspection between
9:30 A.M. or 1:00-1:30 P.M. on day of completio5,..T-elephone Number: 704-634-5985.
Final Installation Diagram: System Installed by
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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 period oftime.
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- APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section r
Mocks Ole N.C.ox 27028 ��C' S
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
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Home Phone
1. Permit Reque d B ��` rs! t �` Business Phone
2. Address
3. Property Owner if Different than Above
Address
4. Permit To: a) Install Alter Repair-,,---
b)
epairb) Privy Conventionaly Other Type
Ground Absorption
c) Sub-Division Sec. Lot No.
5. System used to serve what type facility: House Mobile HomeyBusiness
Industry Other
b) Number of people
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions
Bed Rooms�z;z Bath Rooms 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 urinals garbage disposal
lavatory showers washing machine
dishwasher sinks
8. a) Type water supply: Public—L�Private Community
b) Has the water supply system been approved? Yesle� No
9. a) Property Dimensions-
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 serve?
What type?
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This is to certify that the information is correct to a best of my knowledg
Date Own Signatu
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH LL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
DCHD(6-82)
DAVIE COUNTY HEALTH DEPARTMENT
• Environmental Health Section,
R 0. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION �J
Name Date
Address Lot Size zl-� �
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position S S S
PS PS PS
U U U
2) Soil Texture (12-36 in.) Sandy, S S S S
Loamy, Clayey, (note 2:1 Clay) PS PS PS
U U U
3) Soil Structure (12-36 in.) S S S
Clayey Soils PSS PS PS PS
U U U
4) Soil Depth (inches) pS PS PS
P
U U U
5) Soil Drainage: Internal S S S
PS PS PS PS
U U U
External S S S
PS PS PS PS
U U U
6) Restrictive Horizons
7) Available Space S S S S
g PS PS PS
U U U
8) Other (Specify) S S S S
PS PS PS PS
U U U U
9) Site Classification
U—UNSUITABLE S—SUITAB PS—Provisiona e
Recommendations/Comments:
Described by / Title Date
SITE DIAGRAM
DCMD(6.82)