2268 Davie Academy Rd (3)r J;-
DAVIE 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
c, Sewage Treatment and Disposal Rules (10 NCAC 10A .1934-.1968) Permit Number
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Nam,
e �%%,--._; Date
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/!'".�)` !, _ y• � /"' /ji/ s/`-�/:� - �' � � ! FI / // �/' ' �i' �i: i—.-
Subdivision Name
Name
Lot No
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 p -
Auto Wash Machine YES ❑ NO ❑
Type Water Supply
*This permit Void if sewage system
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is rot 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 completion. Telephone Number: 704-634-5985.
Final Installation Diagram:
System Installed by
Certificate of Completion _
*The signing of this certificate shall indicate that the system describ(
the standards set forth in the above regulation, but shall in NO way be
satisfactorily for any given period of time.
`V�,[iU Date
ve as been installed in compliance with
as a gZiarantee t t the system will function
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
R O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
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Date e �
Lot Size 5�ti'
FACTORS AREA 1 ARFA 9 ARFA 3 APPA A
5)
1) Topography/ Landscape Position S S S
P PS PS
U U U
�) Soil Texture (12-36 in.) Sandy, S S S
Loamy, Clayey, (note 2:1 Clay) PS PS PS
U U U U
3) Soil Structure (12-36 in.) S S S
Clayey Soils (it)PS PS
U U U
d) Soil Depth (inches) S S S
PS PS
—lT U U
Soil Drainage: Internal S S S S
PS PS
U U
External S S S
PS PS
U U
�) Restrictive Horizons
Available Space S S
PS PS PS
U U U U
14) Other (Specify) S S S S
PS PS PS PS
U U U U
9) Site Classification /O
U—UNSUITABLE
Recommendations/Comments:
S—SUITABLE PS—Provisionally Suitable
Described by Title
,SITE DIAGRAM
rf `11
DCHD (6-82)
ate -z�
3)
U—UNSUITABLE
Recommendations/Comments:
S—SUITABLE PS—Provisionally Suitable
Described by Title
,SITE DIAGRAM
rf `11
DCHD (6-82)
ate -z�
3)
APPLICATION FOR SITE EVALUATION/ IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section
R O. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED. Ilk
Home Phone 2 8 4 — 21189
1. Permit Requested By PAu L E s 6,& Business Phone 6a+ , 6? 41 Lrm
2. Address Ar 7 Cox '1210 1 MdGK.SV/L F- 2'702,A
3. Property Owner if Different than Above g►u.►- Koon-r-z-
Address RT Roy, Y7,7 MbGKSYiLA_,. 27o 28
4. Permit To: a) Installl 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 Homed Business
IndustryOtherl".tT \A64 -A, Sr AvA A 3 8.R. Housf- !nr FdT00kA
b) Number of people 3
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions /'s' X ''To '
Bed Rooms 3 Bath Rooms Den w/Closet f
b) If Business, Industry or Other, State: Number of persons served NIA
What type business, etc
Estimate amount of waste daily (24 hou
7. Number and type of water -using fixtures:
commodes 2 urinals O garbage disposal
lavatory Z showers 1 washing machine
dishwasher 0 sinks 3
8. a) Type water supply: Public PrivateCommunity
b) Has the water supply system been approved? Yes No /' * W"'- ho N°r 'c3eg v d uG 1,7r
9. a) Property Dimensions 5 kG2ES C A-PKox also' A 95-0'
b) Land area designated to building site A1,I-
c) Sewage Disposal Contractor Nc,-r ConirR*cr.Eo T4s o,- Y, -r.
10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve?
What type? A Nouse
This is to certify that the information is correct to the best of g!y knowledge.
Date Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
Hwy. G+ WEs /%tK,' A .LEFT ON DAv;,e Ac. acw Ro . ACROSS
fiPoM 17011 Go 2 a -r
DCHD (6-82)
Goo8Y Rb.
p4oP.-R 7'Y
TOU // Gc3itg,E (fid ON' '-e C///<.t't" r
ow