180 Vogler Rd DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTE: Issuedjn.Compliance with G.S. of North Carolina Chapter 130 Article 13c
_ - Sewage Treatment and Disposal Rules (10 NCAC 10A .1934-.1968) Permit Number
Name �. . �� \ ��� \�. -�; .a Date
Location
Subdivision Name Lot No Sec. or Block
Lot Size House Mobile Home Business __ Speculation
No. Bedrooms _� T_ No. Baths No. in Family��—
Garbage Disposal YES F1 NO ❑ Specifications for System:
Auto Dish Washer YES ❑ NO ❑
Auto Wash Machine YES ❑ NO ❑
Type Water Supply
*This permit Void if sewage system 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 Departg�ttent for final inspection of this system between 8:30-
9:30 A.M. or 1:00-1:30 P.M. on day of completion. Telep bne Number: 704-634-5985.
Final Installation Diagram: System Inst Iled by
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Certificateof Completion �_ ��Q Date
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*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.
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT lI
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.
IS
Home Phone ��
1. Permit Requested By 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 Sec. Lot No.
5. System used to serve what type facility: House Mobile Home Ts
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
dishwasher sinks
8. a) Type water supply: Public Private Community
b) Has the water supply systen, Peen approved? Yes No
9. a) Property Dimensions �A(-V
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 knowled e.
V__1 //Li> / - 'rfil-ax kali-0
Date O ner Signature
OWNER IS SOLELY RESPONSIBLE FOR CO PLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
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DCHD(6-82)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section.
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name \ Date I I
Address Lot Size
FACTORS AR 1 ARE:� 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
Loamy, Clayey, (note 2:1 Clay) PS PS
U U U U
3) Soil Structure (12-36 in.) S S S
Clayey Soils PS PS
U U U
4) Soil Depth (inches) S S
PS &D PS PS
U U U
5) Soil Drainage: InternalS S
p PS� PS PS
U U U
External S S
PS PS PS
U U U
6) Restrictive Horizons
7) Available Space S S
PS ('tom PS PS
U U
8) Other (Specify) S S S S
_--- PS PS PS
U U
9) Site Classification S
U—UNSUITABLE — �rovisionally Suitable
Recommendations/Comments:
Described by �, Title � � �� N" Date
SITE DIAGRAM
3
DCHD 18-82