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DAVIE -COUNTY HEALTH DEPARTMENT n�
{ 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 - j•
Name / !�-,/� 'Date ,�� �. - :� t `
k k ... .f} lir
433
Location '"
Subdivision Name Lot No. Sec. or Block No i
Lot-Size House Mobile Home,_ Business - Speculation
No. Bedrooms No. Baths
No.
— .iri Family —
Garbage Disposal YES ❑ NO
Specifications for Systema:
Auto Dish Washer . YES NO ❑ ' - jl
Auto Wash Machine • YES NO•❑
YE
Type Water Supply ! --- ` ` , �C /,�p � .
'.
`This permit Void if sewage system described below is not installed within 36 months from date of issue.
it
' - 4 it
�I
Improvements `permit by
*Contact a representative of the Davie County Health Departme• t f cr al inspection of this system between 8:30- 1i
9:30 A.M. or 1.:00-1:30 P.M. on,'day of completion. Telephone Nu be : 704-634 5985' li
Final Installation Diagram: -' System Ins II d by� _ 0 % Z
071 ?
,:
Certificate of Completion Date
*The signing of this certificate shall indicate that the:system described above has been installed incompliance with:'
the standards set forth in the above regulation, but shalt in NO way be taken as a guarantee that the.system Will function 1,
satisfactorily for any given period of time.
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT} ,,
► Davie County Health Department
Environmental Health Section
P. O. Box 665 ' d+��
Mocksville, N.C. 27028
ZZ
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED. A".�-
cZ
Home Phone 99 f-3407
1. Permit Requested By-72�ntf�CQ'QN 1E, / ,L7R. Business Phone "72?2? - �aa�
2. Address 124F a 460)( /(,Q I MOCAL:Sy 1 l) -7 OQ7
3. Property Owner if Different than Above_Hu-emAq d FOs✓Fe
Address tQ-71 3 nnor-i -sVl ! Ida Ne Q"70aS
4. Permit To: a) Install Alter Repair
b) Privy Conventional Other Type
Ground Absorption
1c) Sub-Division Se . Lot No.
5. System used to serve what type facility: House Mobile Home Business
Industry Other
b) Number of people
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions � i6- °—d%d -70-1 3�
Bed Rooms 3 Bath Rooms 4) 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 3
8. a) Type water supply: Public Private CommunityCo"_
b) Has the water supply system been approved? Yes No
9. a) Property Dimensions c DCU '� x Q(10 16' -
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? /\/C)
What type?
/ This is to certify that the information is correct to the best of my kno ledge.
9
Date Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property: / / dry
R
DCHD(6-82)
r DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION ]
Name 1 Yi Date �✓/�/��
Address Lot Size' tlay
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position S S S S
S' rVS PS
U Cb U
2) Soil Texture (12-36 in.) Sandy, r� �' S S S S
Loamy, Clayey, (note 2:1 Clay) p(� �/. P PS PS PS
U e'ff) U
3) Soil Structure (12-36 in.) / S S S S
Clayey Soils t P PS PS PS
U d5 cinU
4) Soil Depth (inches) S S S S
P PS PS PS
U <E) U
5) Soil Drainage: Internal S S S S
PS PS P PS
U g U
External S S
&P (!P DPS
U U U
6) Restrictive Horizons / Z v
7) Available Space S S S S
S 60PS
U 1 U
8) Other (Specify) S S S S
PS PS PS PS
l' U U U U
9) Site Classification
U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable
Recommendations/Comments:
Described by Title Dater
SITE DIAGRAM
J` die
j
c �
DCHD(8.82)
T
• ; DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name Date
Address Lot Size Z442
2
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape PositionS S
0 PS PS
��5S�..��.
U U
2) Soil Texture (12-36 in.) Sandy, SSS S S
Loamy, Clayey, (note 2:1 Clay) C'U PS PS PS
U U
3) Soil Structure (12-36 in.) S S
Clayey Soils S PS PS PS
U U U
4) Soil Depth (inches) S S S
�� PS PS PS
U U
5) Soil Drainage: Internal Sp
'1� S PS
.:y
(
U U U U
External � S S S
PS PS
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 U U
9) Site Classification
U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable
Recommendations/Comments:
Described by Title Dates–
.
SITE DIAGRAM
I
l
P
Y
DCHD(6-82)