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P5039 Georgia Rd ^Yr�..wY✓v..a.^Y.w-wi+`-u✓�e Jvr✓,Vat.''�'"_ y'». ✓"'.✓aii+.✓-Y I.i-'✓.1f v1W.�.�,:�..�+1-.lt:'."4'—L 7i..:M..'.Y'9'c-"a. � DAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION `NOTE: Issued in Compliance with G.S. of North Carolina Chapter 130 Article 13c Sewage Treatment and Disposal Rules (10 NCAC 10A .1934-.11968) Permit Number Name ;, '> � y� Date - -1- � ` a .S Location Subdivision Name Lot No. Sec. or Block No. Lot Size House Mobile Home Business Speculation No. Bedrooms !!:,F No. Baths No. in Family �= u Garbage Disposal YES p NO Specifications for System: Auto Dish Washer YES 4 NO p Auto Wash Machine YES [t] NO p Type Water Supply -412//� 'This permit Void if sewage system described below is not installed within 36 months from date of issue. v 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 � � i Certificate of Completion _C o 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 be taken as a guarantee that the system will function satisfactorily for any given period of time. V/�f/(f APPLICATI N FOR SITE EVALUATION/IMPROVEMENTS PERMIT ` jV6Davie County Health Department 4 Environmental Health Section t� �►11 d R 0. Box 665 Mocksville, N.C. 27028 VCOtNRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED. Home Phone 1 S sem/ 1. Permit Requested By a h 1,02 a r Business Phone y2 2` 57,57q2. Address "�` (Q 1 Yd 2 2 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 Sec. Lot No. 5. System used to serve what type facility: House Mobile Homes Industry Other b) Number of people 6. a) If house or mobile home, state 11 size of home and number of rooms. House Dimensions--AY- X66 Bed Rooms_— Bath Rooms 2 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 2 urinals garbage disposal lavatory 3 showers '2 washing machine dishwasher sinks 8. a) Type water supply: Public Private f Community b) Has the water supply system been approved? Yes No ' 9. a) Property Dimensions Z2_ b) Land area designated to building site '2 �Z 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 correct to the best of my knowledge. 1 A/&Z Le d&� Date Owner Sign re OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS Allow 5 days for processing Directions to proprle�rty: l l e t=+ on f3 ear e4ek- 0- ►arc , Kaaj, 5-ecemo �;�--- -R OJ 0 I e r=4— /Ifo, 13 /7 • �� �o �a j� o F o ►-, r �.4 5 I P o a d� ©tea DCHD(6-82) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section. P. O. Box 665 Mocksville, N.C. 27028 SOIL/SITE EVALUATION c1 Name— Date Address Lot Size FACTORS AREA 1 AREA 2 AREA 3 AREA 4 1) Topography/Landscape Position S S S PS PS PS U U U 2) 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 PS PS PS U U U 4) Soil Depth (inches) S S S p PS PS PS U U U 5) Soil Drainage: Internal S S S ' PS PS PS U U U External S S S PS PS PS PS U U U 6) Restrictive Horizons 7) Available Space S S S PS PS PS PS U U U U 8) Other (Specify) S S S S PS PS PS PS U U U U 9) Site Classification U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable Recommendations/Comments: Described by =��Z/ Title Date SITE DIAGRAM Lj UCHD(6-82)