P5150 Sanford Ave 0\*w�10�
6WVIE COUNTY HEALT� DEPARTMENT
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IMPROVEMENTS ~~. ~°~~"~.. ~~-""~~"° ° ~
NOTE: /Is ewage Treatment and Disposal Rules (10 NCAC 10A .1934-.1968) Permit Number
NameDate5150
="d.,== ..""= Lot No. Sec. or o/u:x No.
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Lot Size House Mobile Home Business ______ 'Speculation`
No. Bedrooms __�L----- No. Baths —___—__— No. in Fami|y___^L_—_
Garbage Disposal YES �E] NO
Specifications for System:
Auto Dish Washer YES [] NO []
Auto Wash Machine YES E:] NO
Type Water Supply --
*This permit Void if sewage system described below is not installed within 36 months from dobe of issue.
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Improvements permit by \
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°Contacta 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: 704-634-6985. '
Final Installation Diagram:
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Certificate of Completion Date
*The signing of this certificate ohoU in'|cate that the system described obovo has been installed in compliance with
the standards set forth in the above vugu|edion, but shall in NO way be taken as aguarantoo that the system will function
satisfactorily for any given period of time.
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APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT '60Davie County Health Department �� AQR �'
Environmental Health Section c GG,v
P. O. Box 665 'it
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Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone
1. Permit Reque ted By Z e-� �✓e, Business Phone _G3D3.2/
2. Address
3. Property Owner if Different than Above
Address
4. Permit To: a) Instally 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 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
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 showers ✓ washing machine Y
dishwasher sinks
8. a) Type water supply: Public ✓ Private 01E Community
b) Has the water supply system been approved? Yes - No
9. a) Property Dimensions .5raalu)
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? ZVO
What type?
This is to certify that the information is correct to the best of my knowledge.
Date mer Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property: pp �, Jay i SEG GG�tc.
tea, deda, 2�
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DCHD(6-82)
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,,✓, �" DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name �- Date y
Address Lot Size �^
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position S S
&S PS PS
U U U
2) Soil Texture (12-36 in.) Sandy, S S S
Loamy, Cly, (note 2:1 Clay) CAP Is PS PS
�'o I U U U U
3) Soil Structure (12-36 in.) S S S S
Clay Soils Q–P� PS PS
U U U U
4) Soil Depth (inches) S S
JR PS PS
U U U U
5) Soil Drainage: Internal S S
I S3 <t6 PS PS
U U U U
External S S
pS (L PS PS
U U U U
6) Restrictive Horizons
7) Available Space (
S S
42 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: p
ram Q o�
Described by ��– � j Titley- Date
SITE DIAGRAM
DCHD(6-82)