P3110 Jones RdYi
- DAVIE COUNTY HEALTH DEPARTMENT
? IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
'Note: Issued ii Compliance with G.S. of North Carolina Chapter 130—Article 13c.
Permit Number
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Name 1� 2n,.od ��SR'h Date
Location ACA. 2,�L (`{•,-eL Rl R. 11, f Rk� ',Ae-5;.) - -i RA Sf,'R4 11-5
Subdivision Name Lot No. Sec. or Block No.
Lot Size n E S House Mobile Home _ Business Speculation
No. Bedrooms 3 No. Baths ;:2- No. in Family 1A
Garbage Dispoal YES 0 NO 0-
Specifications for System: qpp olcs�`a h � A� �
Auto Dish Was er YES p- NO 0 q-) _ Z
3"X
Auto Wash Machine YES p- NO 0
Type Water Supply \v.,n_1\ __ No Ce e p - �, �. �.S f'c-
`This permit V id if sewage system described below is not installed within 36 months from date of issue.
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Improvements permit by c
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'Contact a repesentative of the Davie County Health Department for final inspection of this system between 8:30-
9:30 A.M. or :00-1:30 P.M. on day of completion. Telephone Number: 704-634-5985.
Final Installation Diagram:
1
System Installed by
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Certificate of Completion Date
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*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.
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. 0. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name o I V. .,
->41?-i7'i��.
Address - V44-2 VeS/ A,' 1/ fed
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041 , /J C -
FACTORS
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Date /?-
Lot Size 3 &,eeJ
AREA 1 AREA 2 AREA 3 AREA 4
Topography/Landscape
2)
3)
5)
x)
8)
Position
S
S
(1111>
S
PS
S
PS
U
U
U
U
Soil Texture (12-":6
Loamy, Clayey, (ote
Loam Cla e ,
in.) Sandy,
2:1 Clay)
w1^
Ste° \� S
S
�"��R' ®
S
PS
S
PS
U
U
U
Soil Structure (12-36
in.)
S
S
S
S
Clayey Soils
�
�
PS
PS
U
U
U
U
) Soil Depth (inche)
,, 40r�
�� S
�i� �
S
PS
S
PS
U
U
U
U
Soil Drainage: Int
rnal
S
S
®
S
PS
S
PS
U
U
U
U
E
ernal
S
�
PS
PS
U
U
U
U
Restrictive Horizons
m'A- 1 a'l 54#o!h
W -t % a 1 l6apr.l
L
40
a
Available Space
S
S.
�P5_�
S
PS
S
PS .
Other (Specify)
S
S
S
S
PS
PS
PS
PS
U
U
U
U
I) Site Classificatio
U—UNSUITABLE
S—SUITABLE PS—Provisionally Suitable
iecommendations
Comm nts: Zioe
D�r�W �C rn. S. S'c=� ' -Mallow s yd. a�XiiG
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3 �l ^'
- /1h� /i" a►.e �ijAw .Ap�' /rw �1/n� C
)escribed by
Title ESV' �ea 1 lon�dl'•wa�� Date
'ITE DIAGRAM
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DCHD (6-82) .. " ♦ . �,
1. Permit Re(
2. Address 1s
3. Property C
Address
4. Permit To:
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APPLICATION FOR SITE EVALUATION/ IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section
- R 0. Box 665
Mocksville, N.C. 27028
NSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED. 73
Home Phone 9 " %,�,Z`;), 744
sted By ) A , Y Business Phone
� . Wa V i4
ier if Different than Above_/ h�a b, LzPa4 In Tom
14�f iYl.� ll�/. w S ����io3 �►. 1 -
Install ✓ Alter Repair
Privy Conventional Other Type
Ground Absorption
c) Sub -Division Sec. Lot No.
5. System used to serve what type facility: House —A -'Mobile Home Business
IndustryOther
b) Number of people '
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions �1? Ya
Bed corns _ Bath Rooms of Den w/Closet
b) If Business, Industry or Other, State: Number of persons served
What type business, etc.
Estim to amount of waste daily (24 hours)
7. Number a id type of water -using fixtures:
comr iodes urinals garbage disposal
'lavat ry showers a' washing machine I
dishwasher sinks
8. a) Type water supply: Public Private '� Community LyL {J 2.0-�`'�"� Lk) �� t
b) Has thE water supply system been approved? Yes il No
9. a) PropeDimensions 1 tU R e6
a e
b) Land a designated to building site n e
c) Sewag Disposal Contractor 7 -P- MOL,t r�
10. Do you a ticipate any additions or expansions of the facility this sewage system is intended to serve? ND
What typ (? No
This is to certify that the information is correct to the best of my knowledge.
Date Owner Sigryfifure
WNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to roperty:
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DCHD (6-82)
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