P3695 Pinebrook School Rd DAVIE COUNTY HEALTH DEPARTMENT
,.IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTE: issued in Compliance with G.S. of North Carolina Chapter 130 Article 13c
ti Sewage Treatment and Disposal Rules (10 NCAC 10A .1934-.1968) Permit Number
Name Dates
Location ��.`• -a_ Y� 7`,. .. ,:, 1_:.:
Subdivision Name ✓ Lot No. Sec. or Block No.
Lot Size %, House Mobile Home _ Business Speculation
No. Bedrooms r No. Baths No. in Family
Garbage Disposal YES ❑ NO ❑ Specifications for System:
Auto Dish Washer YES ❑ NO ❑ �,��;` /: � L rte- 'y i
Auto Wash Machine YES ❑ NO -❑
Type Water Supply
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*This permit Void if sew,a�geisystem described below is not installed within 36 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: System Installed by 41=�f
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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 COUP?TY HEALTH DEPARTIIEdT
ENVIBLONHEBTAL HEALTH SECTION _
SOIL/SITE EVALUATIOU
1%14E DATE
ADDRESS
LOCATION
LOT SIZE
TOPOGRAPHY: vb
SOIL TE:.TUREs
SOIL STRUCTURE: '�llowr/ A-0WAV - ���w'�� //i�
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DEPTH:�(�
RESTRICT I`JE HORIZOPS o� ro�� Y� /D p � ' �• '
PERCOLATION PATE: Presoak Hark & time Drop Time Pate/IIin. Inch
1.
2.
3.
"**CLASSIFICATIOY?:Suitable Pry' Suitable Unsuitable,
COULMEITTS a
SAA?ITARIAIT �/
SITE DIAGFAYI
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CALL
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone
1. Permit Requeste B */ &Z'( Business Phone
2. Address
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 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 an umber of rooms.
i
House Dimensions
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 3 urinals garbage disposal
lavatory showers - washing machine j
dishwasher sinks t
8. a) Type water supply: Public Private Community
b) Has the water supply system been approved? Yes No
9. a) Property Dimensions—
b)
imensions 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?
This is to certify that the information is correct to the best of my knowledge.
49
Date lOwner 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)