819 Dulin Rd DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTE: Issued in Compliance with G.S. of North Carolina Chapter 130 Article 13c '
Sewage Treatment and Disposal Rules (10 NCAC 10A .1934-.1968) Permit Number
Name Date 3753
Location ? 0 - P' 71 „ �` ,. 1, t•
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Subdivision Name Lot No. Sec. or Block No.
Lot Size j`` ,7 c r es House Mobile Home Business ----' Speculation
No. Bedrooms No. Baths Z No. in_Eamily 7 ? 0 t”
Garbage Disposal YES ❑ NO 2- r .J ,---t
Auto Dish Washer YES E;J- NO ❑ Specifications for System: a OD
Auto Wash Machine YES 2 N0 ❑
Type Water Supply (1�u 1-1 _
*This permit Void if sewage system described below is not installed within 36 months from date of issue.
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Improvements permit permit by
*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 bys�
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Certificate of Completion Date
22
'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.
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DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
R 0. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name r-104aeiss WeCPez Date
Address IN, -3s`S��rof�z Lot Size
/yloc4fo://e- AG 7-70
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position (T5 S m S
PSP� PS PS
U U U U
2) Soil Texture (12-36 in.) Sandy, S S S S
Loamy, Clayey, (note 2:1 Clay) s'@;, 'J� (fM dP13::' PS
U U U U
3) Soil Structure (12-36 in.) Nor S Cl S S S
Clayey Soils 5a d!s> (29� elm:> PS
U U U U
4) Soil Depth (inches) it S „ S S S
v� � Zi5> eff§:> PS
U U U U
5) Soil Drainage: Internal S S S S
® dTz> � PS
U U U U
External S 44s:� S S
PS ilS PS
U U U U
6) Restrictive Horizons ZC� p/ 114 "-
7) Available Space S S- S S
4M-:> cm 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:
,,. 1 7y
Described by Title Date 11 - 20
SITE DIAGRAM
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DCHD(6-82)
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT ..r
Davie County Health Department ��5
Environmental Health Section J
P. O. Box 665 Pr 1
Mocksville, N.C. 27028
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CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone ffe— 4/0 S-3
1. Permit Requested By FRXI-4rS We 44. Business Phone
2. Address 3 l3•3C G
3. Property Owner if Different than Above
Address
4. Permit To: a) Install ✓ Alter Repair
sw
b) Privy Conventional Other Type— 0."/-
Ground Absorption
c) Sub-Division Sec. Lot No.
5. System used to serve what type facility: House Mobile Home Business--da a a.¢7 e,«
IndustryOther
b) Number of people— —
eople Z g
6. a) If house or mobile home, state size of home and number of rooms. ZG,,,,( D •��
House Dimensions , _< - 'e �'-
Bed Rooms Bath Rooms 2 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 A/o
lavatory Z showers washing machine Ali)
dishwasher sinks -S!
8. a) Type water supply: Publics Private Community
b) Has the water supply system been approved? Yeses No
9. a) Property Dimensions /6u' -." Via" i T
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? yC_;P�u
This is to certify that the information is correct to the best of my knowledge.
Date Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
DCHD(6-82) Zx