P3842 Hwy 801S` DAVIE COUNTY HEALTH DEPARTMENT
�. IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
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*NOTE: Issued in Compliance with G.G. of North Carolina Chapter 130 Article 13o
Sewage Treatment and Disposal Rules (10 NCAC 10A .1934`1868) Permit Number
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Name ---_-_ Dade � xv,^ �w-^������
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Location
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Subdivision Name Lot No. Sec. or Block No.
Lot, Size � House Mobile Home Business Speculation
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No. Bedrooms No. Baths No. in Family '_!��-_'
GarbaooDis000a
YES :0
NO
Specifications for.System:
Auh}Dish Washer
YES q
NO
Auto Wash Machine
YES [h
NO -E]
Type Water Supply
*This permit Void if sewage system described below is not installed within 36 months from date of issue.
Improvements permit by
°Contaucta representative of the Dave 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. D
ate
^The hi'^g of,?this,certificate, shall indicate ' has been installed in compliance with
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the stAndards 6ei forth in the above regulation, but shall in NO way be taken as a guarantee that the system will function
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satisfactorily period of time.
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_- -/
Improvements permit by
°Contaucta representative of the Dave 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. D
ate
^The hi'^g of,?this,certificate, shall indicate ' has been installed in compliance with
---
the stAndards 6ei forth in the above regulation, but shall in NO way be taken as a guarantee that the system will function
'
satisfactorily period of time.
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APPLICATION FOR SITE EVALUATION/ IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section ��-S'
P. 0. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone Z4 S7 3
1. Permit Requested By //'C1:5 Business Phone
2. Address 39'y,( Ve Tr7-V,'/Z Rs) Ale-- � 7 / r?
3. Property Owner if Different than Above
Address
4. Permit To: a) Install_ Alter Repair
b) Privy_lGConventional Other Type
Ground Absorption
c) Sub -Division Sec. Lot No.
5. System used to serve what type facility: House Mobile Home_/C Business
IndustryOther
b) Number of people Y
6. a) 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 urinals garbage disposal
lavatory showers washing machine /
dishwasher sinks /
8. a) Type water supply: Public Z Private Community
b) Has the water supply system been approved? Yes No
9. a) Property Dimensions
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?
This is to certify that the information is carr ct to the b st of my knowledge.
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3 '
Datener Signature
OWNER IS SOLELY RESPONSIBLE FO IDLIANCE H ALL STATE AND LOCALAWS
Allow 5 days for processing
Directions to property:
�# 7Le 961
ptP-t a��
0
P�
DCHD (6.82)
po
. Address
FA (:Tf1 RR
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Date
Lot Size
AREA 3 APPA A
ARFA 1 APPA 9
Topography/ Landscape Position
S
S
S
S
- PS
PS
PS
'–T
U
U
U
!) Soil Texture (12-36 in.) Sandy,
S
S
S
Loamy, Clayey, (note 2:1 Clay)
PS
PS
PS
U
U
U
1) Soil Structure (12-36 in.)
S
S
S
S
Clayey Soils
�
PS
PS
PS
U
U
U
U
1) Soil Depth (inches)
S
S
S
PS
PS
PS
PS
U
U
U
�) Soil Drainage: InternalS
S
S
PS
PS
PS
PS
U
U
U
External
S
S
S
S
PS
PS
PS
PS
U
U
U
U
i) 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
Recommendations/Comments:
uescnoea Dy _
SITE DIAGRAM
DCHD (6-82)
S—SUITABLE
Title
nally S
011
Date