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DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTE: Issuediin Compliance with G.S. of North Carolina Chapter 130 Article 13c
Sewage Treatment and Disposal Rules (10 NCAC 10A .1934-.1968) Permit Number
,� (� N° f
Name �:7 ` 1' -`> Date58
Location
K Subdivision Name Lot No. Sec. or Block No.
Lot Size L� House Mobile Home _ Business Speculation
No. Bedrooms 3 No. Baths h, 'No.-in Family -
Garbage Disposal ' YES ❑ NO ❑ SP ecifications for SystemAuto Dish Washer YES E) NO C)
Auto Wash Machine YES NO_❑ \�
Type Water Supply, a,
*This permit Void if sewage system described below is not installed within months from date of issue.
B I ,
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: Sjmln,,s� d by
L
o
Certificate of Completion - Date 1, I
*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.
t APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section RECEIVE NOV It W9
R 0. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone
1. Permit Requested B Business Phone ?yl� 1-5
2. Address A
.-3. Property Owner if Different than Above
Address
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 Homed Bs
IndustryOther
b) Number of people 2-
6. ay If house o mobile hom , state size of home and number of rooms.
House Dimensions K / S^
Bed Rooms Bath Rooms Den w/Closet
b) If Business, Industry or Other, State: Number of persons served
What type business,eta
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
8. a) Type water supply: Public Private-.Community
-
b) Has the water supply system 7bgn approved? YesNo
9. a) Property Dimensions
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? ? 5 u.ac�t
This is to certify that the information is correct to the b knowledge.
5'�
Date Ow er Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
-
A�- kr �
*NOTE: Improvements Permits shall be valid for a period of S .
years from .date issued. Improvements Permits are subject
II ;i
to revocation, if site plans or the intended use change.
Effective October 1, .1989.
DCHD(6-62)
�F
DAVIE COUNTY HEALTH DEPARTMENT
' Environmental Health Section.
P. 0. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name Date
Address Lot Size
FACTORS A Al AR 2 AREA"3\ AR
1) Topography/Landscape Position S S
U
2) Soil Texture (12-36 in.) Sandy, S S
Loamy, Clayey, (note 2:1 Clay) <
U U
3) Soil Structure (12-36 in.) C\
Clayey Soils PS
U U U U
4) Soil Depth (inches) S S
U U
5) Soil Drainage: Internal
pS PS
U U U U
External S S - S
PS
U U
6) Restrictive Horizons
7) Available SpaceS S
S PS PS
U U U U
8) Other (Specify) S S S S
PS PS PS PS
9) Site Classification S S
U—UNSUITABLE S—SUITABLE PS—ProvisTonally Suitable
Recommendations/Comments:
IA
Described by Q-1 Title - Date
SITE DIAGRAM
1
DCHD(6.82)