P7780 Marchmont Plantation ;MAVIE COUNTY HEALTH DEPARTMENT
_ r IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTE:Jssued in Compliance With Article II of G.S.Chapter 130a -
Sanitary Sew ge S/ystems Permit Number
Name���) 11 D�� ���1��ilP ate /�-o'��- �,� NO 7780
LocationdA �'.� r �vl` " /_Y•�G�s'.v ®�� _
140
Subdivision Name Lot Lot No. Sec. or Block No.
Lot Size �< yi9� -House Mobile Home Business —_ Industry
No. Bedrooms _ No. Baths — No. in Family_�__ Public Assembly Other
Garbage Disposal YES NO Q Specifications for System:
Auto Dish Washer YES NO ❑
Auto Wash Ma thine YES NO
Type Water Supply _
*This permit Void if sewage system described below is not installed within 5 years from date of issue.
This permit is subject to revocation if site plans or the intended use change.
a1d
t
r
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.,
1:00-1:30 P.M.or 4:30-5:00 P.M.on day of completion.Telephone Number:704-634-5985.
L
Final Installation Diagram: System Installed by
l�
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 any given period of time.
DAVIE COUNTY' HEALTH DEPARTMENT
" r IMPROVEMENTS PERMIT AND,CERTIFICATE OF COMPLETION
-NOTE:Issued in Compliance With Article I I of G.S.Chapter 130a
Sanitary Sewwa a Systems Permit Number
Name �1 Z/� �� �'���f�(�/A � 'Da e -off 7-r�.`i No 7780
Location JIG" r ' rr ri'• rr r c , y _
q0
Subdivision
Subdivision Name � ! Lot No. Sec. or Block No.
Lot Size —y��� House t,'— Mobile Home _� Business -- Industry
No. Bedrooms — No. Baths _ No. in Family�� Public Assembly Other
Garbage Disposal YE44 NO ❑
Specifications for System:
Auto Dish Washer YES NO ❑
Auto Wash Ma^hine YES, NO ❑ C 0" '
Type Water Supply
*This permit Void if sewage system described below is not installed within 5 years from date of issue.
This permit is subject to revocation if site plans or the intended use change.
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t
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.,
1:00-1:30 P.M. or 4:30-5:00 P.M.on day of completion.Telephone Number:704-634-5985.
Final Installation Diagram: System Installed by
G)d
r �
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 regulaffon, but shall in NO way be taken as a guarantee that the system will function%,
satisfactorily for''any given period of time.
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' DAVOICOUNTY HEALTH DEPARTME18
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` Date
Location
Subdivision Name / ' % ' Lot No. / Sec. or Block No.
Lot Size .�% House / Mobile Home _ Business Speculation
No. Bedrooms �'Z No. Baths No. in Family
Garbage Disposal YES NO ❑ Specifications for System:
Auto Dish Washer YES NO ❑
Auto Wash Machine YES NO ❑ �' �/� /r'
Type Water Supply f` _ "i t.•,!i �.' 'f
*This permit Void if sewage system descril5od below is not installed within 36 months from date of issue.
,)IFCiJ
r
� c
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: System Installed by
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 any given period of time.
` APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section
R O. Box 665 R
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone 9748- 5-4;77
1. Permit Requested BytZ,L Business Phone
2. Address /0-T !_O3Q6- C'OCe-Q�(
3. Property Owner if Different than Above
Address
4. Permit To: a) lnstallx_Alter Repair
b) Privy Conventional Other Type
Ground Absorption
c) Sub-Division fiA�@"jf/1 r AD17r Sec. Lot No.-
5.
o.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 ga;C3a ao xa5 ar{,cay4
Bed Rooms Bath Rooms 3 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 3 urinals garbage disposal
lavatory showers 3 washing machine
dishwasher sinks
8. a) Type water supply: Public Private Community
b) Has the water supply system been approved? Yes V No
9. a) Property Dimensions q.7 ACIVIE51
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? NO
What type?
This is to certify that the information is corred to the be y knowledge.
/- /6- y7
Date Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
LS7 lweo7z-ow
DCHD(6-82)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
• SOIL/SITE EVALUATION
�; ewe /i
Name � � � / Date
Address Lot Size
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position S1. S S S
��ssS PS PS PS
U U U U
2) Soil Texture (12-36 in.) Sandy, S S S
Loamy, Clayey, (note 2:1 Clay) PSS PS PS PS
51
-U' U U U
3) Soil Structure (12-36 in.) � S S S
Clayey Soils ( SPS9 PS PS PS
U U U
4) Soil Depth (inches) S S S S
P PS PS PS
U- U U U
5) Soil Drainage: Internal S S S
ps, � PS PS PS
U U U U
External S S S
PS- PS PS PS
U U U U
6) Restrictive Horizons _
7) Available Space S S S S
PS 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 d!
U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable
Recommendations/Comments:
Described by Title
//s��✓ Date
SITE DIAGRAM
Q
DCHD(6-82)
DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
ORKSHEET FOR SEPTIC SYSTEM REPAIR PERMIT
NAMEZ PHONE NUMBER
ADDRESS SUBDIVISION NAME
SUBDIVISION LOT#
DIRECTIONS TO SITE
DATE SYSTEM INSTALLED 1� /
NAME SYSTEM INSTALLED UNDER
SPECIFY PROBLEMS OCCURRING
DATE REQUESTED INFORMATION TAKEN BY //�