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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 .136
Sewage Treatment and Disposal Rules (10 NCACM4.;:1968) Permit -Number'
Name r nntp. -No 5155.
.
Location l�?C ?)k-r: ' V� b ' 'a 1r;t�,�..� �,'C�,r� � Q� z:a V\oc ks 1\1 a
L 01' "'t'`v `
Subdivision Name' Lot.No. Sec. or Block No.
Lot Size h House '' Mobile Home _ Business Speculation
No Bedrooms -_ No: Baths `�-' No,`in Family u
Garbage-Disposal YES ❑. NO Or Specifications for System:
Auto.Dish Washer. YES E]- NO
Auto Wash Machine YES [ NO .,0 r
Type Water,Supply --
--*This permit Void if sewage system described below is not installed within 36 months from date of issue.
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'! ., - '. .. ., ti's 5� ,,�._�`=,...:'^-'•�,.I�....t .+
'= t Improvements permit by e 'J"
kContact a representative of.the Davie County Health Department for final'inspection of this system between 8:30-
'9:30 A.M. or:1:0071':30 P.M,. on day of,completion. Telephone Number: 704-634=5985.
Final Installation,Diagram - System Installed-by
Certificate•of Completion _ Date J b
"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.
Y\
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department —�
Environmental Health Section
P. O. Box 665 -
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
�omeone�0��-
1. Permit Requested By O m t S Business Phoneme l�
2. Address SJ' �e a�0`d
3. Property Owner if Different than Above U 'e
Address `, (o lbs o o.k su i ll.eN Q_
4. Permit To: a) Install Alter Repair
b) Privy. Conventionally Other Type
Ground Absorption
c) Sub-Division ✓ Sec. Lot No.
5. System used to serve what type facility: House Mobile Homed Business
Industry Other
b) Number of people
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions y X o
Bed Rooms Bath Rooms Den w/Closet �/ J
b) If Business, Industry or Other, Sta;e Number of persons served dV /
What type business, etc. A
Estimate amount of waste daily (24 hours)
7. Number and type of water-using fixtures:
commodes IL urinals garbage disposal
lavatory showers c2— washing machine 1
dishwasher sinks 3
8. a) Type water supply: Public Private Community_z: 1. )
b) Has the water supply system been approved? Yes'r No
9. a) Property Dimensions 5 CUA—t—)
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? b
This is to certify that the information is correct to the best of my knowledge.
v;r✓ r
Date Owner Si ature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
Qom, �,, kl 90,P11SI CLW--C)0
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Y'j �' (Du, 6, ICA Q h VS6 ty'S JS°IdV A P)
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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 �1 ��
Name �O-''Date Lf
Address S A'�s'' Lot Size
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position S S
C!L �P PS PS
U U U U
2) Soil Texture (12-36 in.) Sandy, S S S
Loamy, Clayey, (note 2:1 Clay) (h PS PS
U U U
3) Soil Structure (12-36 in.) S S S
Clayey Soils PS PS
U U U
4) Soil Depth (inches) S S
Ap PS PS
U U U
5) Soil Drainage: Internal S S S
�P `> PS PS
U U U U
External $ k-1 S S
PS, PS PS
'--
U U U U
6) Restrictive Horizons
7) Available Space S S S
<:k5 PS PS
U U U
8) Other (Specify) S S S S
PS PS PS PS
U U U
9) Site Classification S
U—UNSUITABLE S—SUITABLE P Provisionally Suitable
Recommendations/Comments:
Described by
Title �� Date "fib5�
SITE DIAGRAM
F
AA
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DCHD(5-82(