P4974 Underpass Rd . -, DAVIE COUNTY HEALTH DEPARTMENT
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IMPROVEMENTS PERMIT'�AND. CERTIFICATE OF COMPLETION
,r- ' OTE.;Issued in Compliance with G.S.,of North Carolina.Chapter 130 Article 13c
Sewage Treatment'and Disposal Rules (10':NCAC-10A 1934=.1968)',"' ;'t € f <^' '• Permit;,Number.:'"''`
' Name l�ate' � �;?' ��" ® 4974 "°""-
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Location +; 7 -111I- �L , \�� C ` _may,_ ,
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Subdivision Name U Lot No. Sec or Block No.,
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Lot'Size f 1 G, House ✓ . Mobile Home_ Business. Speculation � `�'� +,
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No, Bedrooms •_1121 No;`Baths � � 'No.•in Family_ �t ' '''" �`'�
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-�z Garbage Disposal YES ] NO "' �"� �" A� - y +
1111�, , Specifications for:System; l`,�,1 ," " 1., x
',:Auto Dish Washe�� YES NO:fl > + 'j- 1
1. Auto Wash Machine "'YBS:,�1.�NO fl . ' + `{" x ` ! ��' I t „�`� _, :�
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Type, Water,Supply ;,tom _ �' t .�( �.1k
`I 1 61This permit Void if sewage s described below is not �nstalied within 36 moths from date of issue t', ,}< '-
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. : t';i.Improvements permit by �� �-Y'-
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*Contact a representative of the Davie County Health:Department for final inspection-of this, system betweep'8I 01
30
9:30 A.M. or 1:00 1 30 P M. on day of;completion Telephone Number `704;634 5985 I I
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�FiAal Installation Diagram, : ' , 'i xt' ' ' (. System Installed by
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. :Certificate of Completion , L s' '` Date' .V6 �' 1 ^,f,
*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 f1 .orany given period of•time
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,,. Ar-r1-,!-.:TION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department �
/y 1 Environmental Health Section 7%
U' P. O. Box 665
/ Mocksville, N.C. 27028
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CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone (t(t6 q(e
1. Permit Requested By
Business Phone N4 (RCS'-!�
2. Address LKC15 S _) 9lo'4
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 Home Business
Industry Other
b) Number of people I
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions 3 Q x 24
Bed Rooms ( Bath RoomsImo—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 2 urinals garbage disposal
lavatory Q •showers ( washing machine
dishwasher ( sinks
8. a) Type water supply: Public Private Community
b) Has the water supply system been approved? Yes No
9. a) Property Dimensions
b) Land area designated to building site 1T a$ acrj,
c) Sewage Disposal Contractor
10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve? /lam
What type?
This is to certify that the information is correct to the best of my knowledge.
/p I
Date Owner Signat re
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
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-Directions to property:
+a � Ur\8St'pass fid , o-' oj� $OI _ 'AaL, ori U r &r-f ass �d .
II -1\s o Qrao�_-1 A �L,_r-r,s back -Lo p av �!n.F.eA a-� 3or\'Cs
�a E l6-4 �„� �kE �urS �rc� cross raJrload J_'rack.s
16k a r,d go
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DCHD(6-82)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section.
P. 0. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name � � `� o Date
Address C,\Xca0- Lot Size-
FACTORS AR 1 AREb AREA 3 AREA 4
1) Topography/Landscape Position S S
P$� PS PS
U U
2) Soil Texture (12-36 in.) Sandy, S S
Loamy, Clayey, (note 2:1 Clay) PS PS
U U U U
3) Soil Structure (12-36 in.) S S S
Clayey Soils 'S PS PS
U U U
4) Soil Depth (inches) S S
pS A PS PS
U U U
5) Soil Drainage: Internal S S
p PS PS
� U U U
External S S
OPS PS PS PS
U U U
6) Restrictive Horizons
7) Available Space S S S S
PS PS
U U U U
8) Other (Specify) S S S S
PS PS PS
c U U
9) Site Classification S J
U—UNSUITABLE S—SUI E PS Provisionally Suitable
Recommendations/Comments:
Described by��4h Title �c Date u-g�
SITE DIAGRAM
DCHD(6-82)