P3995 Cornatzer RdDAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
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*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 iGf,
n �`.-i 3
�r - �' r';, . v, Dated/��
Location ,r`'%f s`
Subdivision Name Lot No. Sec. or Block No.
Lot Size House Mobile Home ✓ Business Speculation
No. Bedrooms No. Baths — Z No. in Family_
Garbage Disposal YES p NO
p Specifications for System:
Auto Dish Washer YES NO
Auto Wash Machine YES E NO ❑ /�'C s j'"-{ �/
Type Water Supply
*This permit Void if sewage system described below is not installed within 36 months from date of issue.
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 completjon. Plep,hone Number: 704-634-5985.
Final Installation Diagram:
System Installed by �n'-rJ�-
S�w T
Ccr.,, o-1 D, (-r--
Certificate of Completion _ ���?� ?'- �• °��
*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.
Name—
Address
FA f .TC1 RC
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Date qvl�7&,t�
Lot Size&te
AREA 3 AREA 4
AREA 1 ARFA 9
Topography/ Landscape Position
S
S
S
PS
PS
PS
PS
U
U
U
U
!) Soil Texture (12-36 in.) Sandy,
S
S
S
Loamy, Clayey, (note 2:1 Clay)
(tp
PS
PS
PS
U
U
U
U
I) Soil Structure (12-36 in.)
S
S
S
S
Clayey Soils
PS
PS
PS
U
U
U
Soil Depth (inches)
S
S
S
S
PS
PS
PS
U
U
U
) Soil Drainage: Internal
S
S
S
S
PS
PS
PS
U
U
U
External
S
S
S
S
PS
PS
6F5
U
1) Restrictive Horizons
') Available Space
S.
S
S
PS
PS
PS
U
U
U
U
1) Other (Specify)
S
S
S
S
PS
PS
PS
PS
U
U
U
U
1) Site Classification
,
U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable
Recommendations/Comments:
i
Described byTitle
SITE DIAGRAM
M
Date
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 9 910` � 0 c�//
1. Permit Requested By Ua 1%I*S !a abD Business Phone
2. Address A 7 &C Z7 %6At U14Z.L''' - �'72a�f
3. Property Owner if D
Address
than Above
4. Permit To: a) Install —"Alter Repair
b) Privy ConventionalZ Other Type
Ground Absorption
c) Sub -Division Sec. Lot No.
5. System used to serve what type facility: House Mobile Home k!� Business
IndustryOther
b) Number of peo e
6. a) If house o mobile ome, state size of home and number of rooms.
House Di (ons / �X
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) r-
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 L� ,
b) Has the water supply system been approved? Yes ✓ No
9. a) Property Dimensions % AC -X Z
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? Tl
What type?
This is to certify that the information is correct to the best of my kno ledge.
4
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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"ev //� '�Y
,61,�
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DCHD (6-82)