P3145 Bailey Rd 4 , DAVIE' COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
`Note: Issued in Compliance with G.S. of North Carolina Chapter 130—Article 13c.
Permit Number.
Name t r . i'' ter f �' Date-71
Location W,
Subdivision Name Lot No. Sec. or Block No.
Lot Size Houses!' Mobile Home _ Business -- Speculation
.No. Bedrooms ` -' No. Baths j No. in Family
Garbage Disposal YES ❑ NO Z Specifications for System:,
Auto Dish Washer YES 'T NO E] ^,✓ •� ;,off' ';1-:r4 :..
Auto Wash Machine YES ® NO •❑
Type Water Supply l..z1? 14& .
*This permit Void if sewage system described bel w is not installed within 36 months from date of issue.
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Improvements permit by 'r
"Contact a representative of the Davie County Health Department-for final inspection of this system between 8:30'-
9:30
:30-9:30 A.M. or 1:00-1:30 P.M. on day of completion. Telephone/ umber: 704-634-5985.
Final Installation Diagram: ystefi Installed by
f
-93
Certificate of Completion Date /// y
'The signing of this certificate shall indicate that the system descri�d 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.
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APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
a Davie County Health Department
Environmental Health Section
- R O. Box 665
Mocksville, N.C. 27028
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CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone
1. Permit Reqqested By f• a � r Business Phone
2. Address C X/ E�R,UI:e,.Y_• ('�� cif?nD<o
3. Property Owner if Different than Above
Address
4. Permit To: a) InstallZ Alter Repair
b) Privy Conventional Other Type
Ground Absorption
c) Sub-Division Secy Lot No.
5. System used to serve what type facility: Housed Mobile.Home Business
IndustryOther
b) Number of people
6. a) If house or mobile home, s®tatte, 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 a showers washing.machine /
dishwasher sinks �'-
8.,a)Type water supply: Public Private—Community
b) Has the water supply system been approved? Yes Nom
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?
This is to certify that the information is correct to the best of my knowledge.
Date 0 OviVer Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property: /
15$ g�f
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tDCHD(6-82� ,
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DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
R O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name Date
Address Lot Size
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position � S S S
PS --25� PS PS
U U U U
2) Soil Texture (12-36 in.) Sandy, S SS S
Loamy, Clayey, (note 2:1 Clay) PS PS
U U U U
3) Soil Structure (12-36 in.) S S S S
Clayey Soils `ZEfj � PS PS
U U U U
4) Soil Depth (inches) S S S S
C�
1-1� PS PS
U U U U
5) Soil Drainage: InternalST,— S S S
p�/ Cf9F-> PS PS
U U U U
9705
External S S
PS PS PS PS
U U U U
6) Restrictive Horizons
7) Available Space 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
U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable
Recommendations/Comments:
d b Title �� Date
Described y
SITE DIAGRAM
DCHD(6-82)