173 Wall St \.
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DAVIE COUNTY HEALTH DEPARTMENT V
IMPROVEMENTS PERMt''AND CERTIFICATE OF COMPLETION fes_
'*NOTE;'Issued in Compliance With Article II of G.S."Chapter 130a
Sanitary Sewage Systems Permit Number
Name N2 5841
Location
Subdivision Name Lot No. Sec. or Block No.
Lot Size House Mobile Home _ Business Speculation
No. Bedrooms — No. Baths No. in Family;'
Garbage Disposal YES ❑ NO 2" Specifications for System:
Auto Dish Washer - YES NO E] � -•.---
Auto Wash Machine YES Ll NO ❑
Type Water Supply _
*This permit Void if sewage system described below,is not installed within 5 years from date of issue.
This permit is subject to revocation if site plans or�,he intended use change.
Improvements permit by r.' / /
*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
f
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.
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
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Davie County Health Department
• r rr`` Environmental Health Section 1T
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P. 0. Box 665 RECVIVED •,A�
Mocksville, NC 27028
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1 . Application/Permit Requested By eml Jnr
Mailing Address P0, &,(' 9y� 6_00/ee ynee_
Home Phone Business Phone
2. Name on Permit if Different than Above
3. Property Owner if Different than Above
4. Application/Permit For : 0 General Evaluation S/Tank Installation
5. System to Serve: I' House Mobile Home 0 Business
0 Industryu Other 0 Unknown
6. If house, mobile home: Subdivision Sec. Lott
No. of People I Dwelling Dimensions o` �/r 74
No. of Bedrooms Basement/Plumbing
No. of Bathrooms a Basement/No Plumbing
e'Washing Machine 0 Dishwasher 0 Garbage Disposal
7. If business, industry, other: Specify type
No. of People Served No. of Sinks
No. of Commodes No. of Urinals
No. of Lavatories No. of Water Coolers
No. of Showers
S. Type of water supply: C Public ? 0 Private 0 Community
9. Property Dimensions a' m ' 1 h of L
10. Sewage Disposal Contractor
11 . Do you anticipate additions/expansions of the facility this system is
intended to serve? 0 Yes p/No
If yes, what type?
*NOTE: Improvements Permits shall be valid for a period of 5
years from date issued. Improvements Permits are subject
to revocation, if site plans or the intended use change.
Effective October 1, 1989.
This is to certify that the information provided is correct to the
best of my knowledge, and I understand I am responsible for all
charges incurred from this application.
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Directions to Property : #talhl wad
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DCHD (10-89)
I
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. 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 11-0S
P PS
U U (V
2) Soil Texture (12-36 in.) Sandy, S,' S S S
Loamy, Clayey, (note 2:1 Clay) (QS� P (I p
3) Soil Structure (12-36 in.) S S S S
Clayey Soils PS ( PS
4) Soil Depth (inches) S � S
PS' P ( P5/ PS
5) Soil Drainage: Internal S S S S
PS — PS
U
External S -�
c S (�Pls /I
6) Restrictive Horizons
7) Available Space
S
PS PS SS
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:
Described by � '�� Title Date
SITE DIAGRAM (/
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DCHD(6.82)