6538 Hwy 801S (2) -�A! .
!_ DAVIE COUNTY HEALTH DEPARTMENT --eaq-6 r
j� 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 r /A , r Date I.
Location
Subdivision Name Lot No. Sec. or Block No.
Lot Size _ House Mobile Home Business Speculation
No. Bedrooms ��_ No. Baths _�_ No. in Family
Garbage Disposal YES ❑ NO [] Specifications for System:
Auto Dish Washer YES ❑ NO C] /%> i ,�"
Auto Wash Machine YES NO ❑ �,,
Type Water Supply
`This permit Void if sewage system descnbed below is not installed within 36 months from date of issue.
1
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'Improvements permit by
i
`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: System Installed by
r` --------------
/7 /,->�
Certificate of Completion W, . /� date'
'The signing of this certificate shall indicate that the system described above has been installed in compliant .m -
the standards set forth in the above regulation, but shall in NO way be taken as a guarantee that the systew- ill function
satisfactorily for any given period of time.
T ' ! APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT �¢C �5
Davie County Health Department
Environmental Health Section
P. 0. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone -Z Z
1. Permit Req4ested By Business Phone
2. Address - /
3. Property Owner if Different than Above
Address
4. Permit To: a) Installer Alter Repair
b) Privy Conventional Other Type
Ground Absorption
c) Sub-Division Milid ,"41'l°t Sec. Lot No.
5. System used to serve what type facility: House Mobile Home--ZBusiness
IndustryOther
b) Number of people
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions 2 x '7 '
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 . ` t showers 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 t crc P�
b) Laid area designated to building site
C) Sewage'Disposal Contractor 041 r
10. -Do you anticipate any additions or expansions of the facility this sewage system is intended to serve? m
What type?
This is to certify that the information is correct to the best of my knowledge.
/�- 3d Y5
Date Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
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DCHD(6-82) Ago
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: - DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
R O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name PUSS Date �//Z;; W
Address Lot Size -40. �D6
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position S S S S
61 PS PS PS
U 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 S
Clayey Soils 0 PS PS PS
U U U U
4) Soil Depth (inches) S S S S
40, PS PS PS
U U U U
5) Soil Drainage: Internal S S S S
/p� PS PS PS
�j U U U
External �S S S S
c� PS PS PS
U U U - U
6) Restrictive Horizons ��-
7) Available Space S S 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 F
U—UNSUITABLE S—SUITABLE �tP�roisiio�nallySuitable
Recommendations/Comments:
Described by ! Title Date lam`
SITE DIAGRAM
DCHD(6-82)
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