486 Deadmon Rd Lot 2DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTE: Issued in Compliance With Article II of G.S. Chapter 130a
Sanitary Sewage Systems �, t `'' Permit Number
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Name fry% �`. j ;<"'7/!, L1 i;r�:, ,,� s 1r'. Date f �ci �' % N2 7006
Location 1 —
(l'.�' � � � 1 � �-J _.. .- `\ ~�� w I �. ._. ..tib.-� • �` - `
Subdivision Name�� �I c t = ` Lot No. 2r– Sec. or Block No.
Lot Size �` �� �` House Mobile Home Business _— Speculation
No. Bedrooms .No. Baths_ No. in Family _
Garbage Disposal YES ❑ NO ❑ Specifications for System:
Auto Dish Washer YES NO ❑ f `` - t ` , _.
Auto Wash Ma thine YES p NO ❑
Type Water Supply
3
*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 the intended use change.
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Improvements 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 by
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Certificate of Compl
*The signing of this certificate shall indicate that the system
the standards set forth in the above regulation, but shall in�NI
satisfactorily for any given period of time.
lescribed at
way be take
Date
ove has been installed in compliance with
i as a guarantee that the system will function
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APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section
P. O. Box 665
Mocksville, NC 27028
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1. Application/Permit Requested By
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Mailing Address
Home Phone qZ %C
Business Phone
2. Name on Permit if Different than Above
3. Application/Permit for: ElGeneral
Evaluation
Septic Tank Installation
4. System to Serve: C9/ House
❑ Mobile Home
❑ Place of Public Assembly
❑ Business ❑ Industry
❑ Other
❑ Unknown
5. If house, mobile home: Subdivision
Section Lot #�
❑ Basement/Plumbing
No. of People
❑Basement/No Plumbing
No. Bedrooms
Q/Washing Machine
of
No. of Bathrooms ?i
Dishwasher
Dwelling Dimensions Z9,S-t-5�4 ET•
❑ Garbage Disposal
6. If business, industry, place of public assembly, 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
Water Usage Figures
7. Type of water supply: Public
❑ Private
/ El Community
8. Property Dimensions -
Sewage Disposal Contractor
Ye,, -1 prcA.'orJ
9. Do you anticipate additions/expansion of the facility this
sytem is intended to serve? ❑ Yes 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.
/Directio/ns to Property:
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0 t — J�°U h -ra �C�c(�noc� V 6-6 �/�acl7 % vh , t /�� vse ux,
L c f 5�1r- o � V,
This is to certify that the information provided is correct to the best of my
incurred from this application.
�r/93
—DATE
, and I
SIGNATURE
I am responsible for all charges
CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY
MUST CHECK ONE: 1. 1 OWN the property. O 2. 1 DO NOT OWN the property.
If you checked Box #2, the rest of this form MUST be completed by the owner or a person authorized by the owner:
1 hereby give consent to the authorized representative of the Davie County Health Department to enter upon above described
property located in Davie County and owned by
to conduct all testing procedures as necessary to determine said site's suitabi�l' for a ground ab7 rption sewage treatment
and disposal system. 1-7V xv ,—
DCHD (12-90)
DATE 6/ SIGNATURE
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department
........... .
Environmental Health Section
P. 0. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone a Da
1. Permit Requested By �-- v 1= Dm Z),-%( Business Phone
2. Address . 71 o X Li, N-0 c //i= h X' oZ iv 2
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. %L '
5. System used to serve what type facility: House Mobile Home Business — S."N
IndustryOther 140 � j IF -4 AP Jr- -
b) Number of people Ir
6. ay 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 I urinals garbage disposal
lavatory showers washing machine I
dishwasher I sinks
8. a) Type water supply: Public k"__ Private Community
b) Has the water supply system been approved? YesL�No
9. a) Property Dimensions I Z> 0 0
b) Land area designated to buildipsite �t
c) Sewage Disposal Contractor '-J A :!� 1-5 / C
10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve? A10
What type?
This is to certify that the information is c rect 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:
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DCHD (8.82)
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50 4-4
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DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION q
Name Date
Address
Lot Size
FACTORS ARFA i ARFA 9 ARFA 3 APPA A
t) Topography/ Landscape Position
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2) Soil Texture (12-36 in.) Sandy,
Loamy, Clayey, (note 2:1C��
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U
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PS
U
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PS
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3) Soil Structure (12-36 in.)
Clayey Soils
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U
S
PS
U
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PS
U
I) Soil Depth (inches)
PS
S
PS
U
S
PS
U
i) Soil Drainage: Internal
U
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PS
U
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PS
U
External
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U
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PS
U
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PS
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i) Restrictive Horizons
Available Space
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PS
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PS
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I) Other (Specify)
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PS
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PS
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PS
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PS
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1) Site Classification
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U—UNSUITABLE S--�SurrA—BLE PS—Provisionally Suitable
Recommendations/ Comments: �o�� — a��` R� G
Described by ��--�Title �i`t� Date
SITE DIAGRAM j o�
DCHD (6-82)
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