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DAVIE COUNTY HEALTH"DEPARTMENT' -
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
NO E: Issued in.Compliance with G.S.,of `North Carolina Chapter, 130 Article 13c
Sewage Treatment' and, Disposal Rules (10 NCAC'10A .1934-:1968) Pettit Ntimbe1'
Name 2 ;� - � 7� AU/ ' Date ��-<"— 'y e 6.
location - i..•z` T1 '?,7 ,T 1, . , 1 �� . =,� ``o� r i` ✓' ''
' tom. �,�:r",'V _ _ .. : . . . ' - •.
Subdivision NameLot No. Sec. or Block No.'
-Lot Size ( House ��- Mobile Home'_ Business Speculation
I No. Bedrooms No. Baths — — No. in Family _—
Garbage Disposal; YES NO.'`' Specifications 'for System:
•Auto Dish Washer YES NO.:. JU ,
Auto Wash MachineYES - NO :p 3 f {�,
)..X x
Type. Water Supply'
*This permit Void if sewage system described below is not installed within 36 months from dat f issue_
r 1 ae
Improvements permit by.,—
*Contact a representative of the Davie County ea h Department for final inspection' of,•this system between 8:80-,.
9:30 A.M. or,1;00-1:30 P.M. on day of com etio Telephone Number. 704-634-5985.•
Final Installation-Diagram. System Installed by
�uovl.
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,wilf function_
satisfactorily for any given period of time.
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
0, Davie County Health Department
Environmental Health Section
P. O. Box 665 / ','3 �F
Mocksville, N.C. 27028 �98�
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone �?e 0-65 2
1. Permit Requested By e-r Business Phone l rIT -e2-2-4707
2. Address Kf .2- Ban 2_6 cQ Kce--
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
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions
Bed Rooms 2- 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 system been approved? Yes lrNo
9. a) Property Dimensions 5- �_«v-- S
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 correc the!Vf owledge.
�. -ZO -e?
DateO ignature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH LL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property: '�e'
o�
b
6-8
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 yySSS S S
(PSS PS PS PS
U U U
2) Soil Texture (12-36 in.) Sandy, S S S
Loamy, Clayey, (note 2:1 Clay) PS PS PS
U U U
3) Soil Structure (12-36 in.) S S S
Clayey Soils PS PS PS PS
U U U
4) Soil Depth (inches) S S S
PS PS PS PS
U U U
5) Soil Drainage: Internal S S S
PS PS PS
U U U
External S S S
PS PS PS PS
U U U
6) Restrictive Horizons
7) Available Space SS S S
g 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:
,�51��
Described by Title Date
SITE DIAGRAM
DCHD(6-82)