369 Hillcrest Dr DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
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*NOTE: |aouod in Compliance with G.G. of North Carolina Chapter 130 Article 13o
Sewage Treatment and Disposal Rules (10 NCAC 10A .1934-.1968) Permit Number
Name Da�e
.
Location
Subdivision
Subdivioion Name Lot No. Goo. or Block No.
Lot Size [> - � House Mobile Home —_--__--- Business —___—_—_ Speculation
No. Bedrooms No. Baths No. in Fomi|y—_���_—_ �
Garbage Disposal YES E�f NO [] . Specifications for System:_
Auto Dish Washer ^
Auto Wash Machine YES [DI NO
Type Water Supply
°Thia permit Void if sewage system described below is not installed within 38 months from date of issue.
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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 fX System Installed by-
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CerUficabooUCompetion Date
*The signing of this certificate^ shall indicate that the
^ 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
Environmental Health Section 0
P. 0. Box 665
Mocksville, N.C. 27028 `
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone 9/9- IIb5&41gV
1. Permit Requested By
��U ( E� ��2 p�([� Business Phone q1? Q gjpa 0 a
2. Address W-3 sok 1664 ALZI_10Of 4 Dk1/J,Pr 1/8-Pee–.
3. Property Owner if Different than Above
Address rPoc) .6- oS 4)';L'/Ae /e to
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
Industry Other
b) Number of people 1
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions 3 ('o / X SS/
Bed Rooms— �-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—a washing machine
dishwasher sinks"
8. a) Type water supply: Public ✓ Private Community
b) Has the water supply system been approved? Yes `No
9. a) Property Dimensions �6 �� go
b) Land area designated to building site 0
c) Sewage Disposal Contractor NO10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve?
What type?
This is to certify that the information is h best of my knowledge.
®correctto
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Date 040her ignature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
- 40 �o '?o l So wA/oa ef] ed b 6,f,
ea�41 on fl�
DCHD(6-82)
DAVIE COUNTY HEALTH DEPARTMENT
• Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
SOIL/ ISOIL/QITc EVALUATION
Name Date
Address Lot Size
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position S -_ S S S
c�a PS PS
U U U U
2) Soil Texture (12-36 in.) Sandy, S S
Loamy, Clayey, (note 2:1 Clay) PS PS PS
U U U U
3) Soil Structure (12-36 in.) S S
Clayey SoilsIF
PS PS
V"' U U
4) Soil Depth (inches) S S S
PS PS
U U U U
5) Soil Drainage: Internal � �S� S S
`.-= !—!L PS PS
U U U U
External S S S
�S PS PS
U U U U
6) Restrictive Horizons
7) Available Space S S
PS PS PS
U U U U
8) Other (Specify) S S S S
PS PS PS PS
U U
9) Site Classification
U—UNSUITABLE S—SUITABLE PS— rov(s)onaliy Suitable
Recommendations/Comments:
Described by Title `- - Date y 'V
SITE DIAGRAM
J�o, ° r
V'U
L ,
c .01
0/y
4 '�
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DCHD(6-82)