142 Lybrook Rdo
DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
'NO'TE: issued in Compliance with G.S. of North; Carolina Chapter 130 Article 1.3c'
Sewage Treatment and,Disposal Rule`s•:(1'0.NCAC 10A .1934-.1968) Permit Number
Name �• �� ����`► Date
Location
Subdivision Name Lot No. Sec. or Block No.
Lot Size House Mobile Home _ Business Speculation
No. Bedrooms No. Baths;_ - { No.. in Farhily �a
Garbage Disposal �' :.YES; td NO �'
• Specifications for System: •' •
Auto -Dish Washer YES NO ❑ ' _ -
'Auto Wash' Machine 'YES'NO
X1 -'I 1
Type Water Suppl,�
y —a
*This permit Void if sewage system described below isnot installed within 36 months from date - of issue.
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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 Diagr m: System Installed by,
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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 betaken as a guarantee that,the system will function
satisfactorily for any given period.of time:
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APPLICATION FOR SITE EVALUATION/ IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section
P. 0. Box 665
M 'll N C 27028
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CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
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•'� 1.
Home Phone 43 �L— 3 D� 7
1. Permit Requested By Doan L. h g�L L Business Phone c
2. Address /iaV yab%/IJVILLi l _`7jjoCksu/&EE:� . AI C'__ 2'I4.7--
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 PAW ret r 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 / X 3q,'312 -Son V� 29. g X 2�8 �T7ACHE�O GA/2AG,G
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 hou
7. Number and type of water -using fixtures:
commodes 3 urinals a garbage disposal
lavatory fL showers washing machine
dishwasher 1 sinks 2
S. a) Type water supply: Public—vff Private Community
b) Has the water supply system been approved? Yes_ZNo
9. a) Property Dimensions 33 q 17 / X Z/7 2 , G 7 k 2 7 D, 3 �k k
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? Nd
What type?
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:
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DCHD (6-82)
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Address
FArTOPR
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
AREA1l ARErA 2l
Date
Lot Size )
ARE AREA 4
Topography/ Landscape Position
S(is
AP
PS
U
U
U
U
!) Soil Texture (12-36 in.) Sandy,
Loamy, Clayey, (note 2:1 Clay)
S
Deb
S
PS�
S
S
PS
U
U
U
U
1) Soil Structure (12-36 in.)
Clayey Soils
A(�
S
S
S
PS
U
U
U
U
Soil Depth (inches)
S
S
PS IPS
S
U
U
U
U
Soil Drainage: Internal
S
(Ab
SS
CE —Sr�
PS
—l1S
U
U
U
External
�
i
�—P5
S
PS
U
U
U
U
i) Restrictive Horizons
Available Space
�—'
PS
'
PS
PS
S
PS
U
U
U
U
!) Other (Specify)
S
PS
S
PS
S
PS
S
PS
U
U
U
U
1) Site Classification
Q
S
U—UNSUITABLE
Recommendations/ Comments:
Described by
SITE DIAGRAM
DCHD (6-82)
S—SUITABLE PS—Provisionally Suitable
Title • --"� Q�' Date J J , u P.