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319 Elmore Rd (2) gu ta:..:.:8 ';.r'. `. ..� t: e:.r ,... ::. .v "-^:p't Li .; a +m..:', c ' l r ..1<:.. �.'".ty.',1♦ .. J r .. .f-F. .. .. ... - . - .rye ' DAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION *NOTE- sued in Compliance with G.S. of North Carolina Chapter 130 Article 13c Sewage/Treatment and Disposal Rules (10 NCAC.I OA .1934-.1968) Permit Number Name 112&fa �1 l,� )97(,Ik Date y7, _�2d JR�l,P N2 . Location /,e2�� ,/�tT �:1��.� — ZZ � �� 0 /K ?�'/ Subdivision Name Lot No. Sec. or Block No. x Lot Size House Mobile Home .t` Business Speculation No. Bedrooms _ No. Baths_ Z _ No. in Family Garbage Disposal YES ,1] NO ®' Specifications for System: Auto Dish Washer YES p NO {�J- Auto Wash Machine YES 2-'NO C] 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 completion. Telephone Number: 704-634-5985. Final Installation Diagram: System Installed by Certificate of Completion 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. i AIL, V 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 clgg- 70510 1. Permit Request d By Business Phone 2. Address14.5-9- 13 1° NC 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 N 5. System used to serve what type facility: House— bile Ho me Business IndustryOther b) Number of people 42-1 6. ay If house or mobile home, state size of home and number of rooms. House Dimensions 1k X 10 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 0 sinks oZ 8. a) Type water supply: Public Private Community b) Has the water supply system been approved? Yes No 9. a) Property Dimensions -�{ -tu'.4 c2�a, b) Land area designated to building site c) Sewage Disposal Contractor 10. Do you anticipate any additions or expansionsof the facility this sewage system is intended to serve? What type? -horn-. fu build 'L- ha lye it —3 Sj A cs4;,Y� This is to certify that the information is correct to the best of my knowledge. :2- 1 L oam • Date bwner Signature OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS Allow 5 days for processing 0 t N -tv 1.A Chi tr c h. Rd . Directions to property: �"a _:I_ � �I to w l-i b C 1U rd-) K-CA Url-E-i V-0 ad berms (0 wh i*�"K; 'Wi d b e O cd . 80- TilC IS + dir+ road ©n -I-he L �s whe c, 11.0c Ou r)eed -f'D -{urn -Thc pro put � 5 o ock,-V1 pro rna�eI to p -F Q +m, Ie � )VI mad � 6)-F �cp • Thlc'•e i 5 a bl ue. ry\sarkms' d ividir� �a 6e,Chons a� (and DUO 15 CA051e5T- f0 +1'\C ��- II lawl p DCHD(6-6q U�o ?1.9 Ae s )Rik N IT) 14 o a , N6cASE DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section. R 0. Box 665 Mocksville, N.C. 27028 SOIL/SITE EVALUATION ��Name / Date Address Lot Size FACTORS AREA 1 AREA 2 AREA 3 AREA 4 1) Topography/Landscape Position S S S S 1:2 111�5 e �, 2) Soil Texture (12-36 in.) Sandy, S S S S Loamy, Clayey, (note 2:1 Clay) 41 3) Soil Structure (12-36 in.) S S S Clayey Soils PS / U 4) Soil Depth (inches) S V PS S U 5) Soil Drainage: Internal V U U U U External :Ps:�- —(�[__...111 U U 6) Restrictive Horizons 7) Available Space �— PS PS PS PS U U U U 8) Other (Specify) S S S S PS PS PS PS U U 9) Site Classification 701-11s, c U—UNSUITABLE S—SUITABLE PS— rovisionaliy Suitable Recommendations/Comments: —� J Described by Title Date SITE DIAGRAM UCHD(6.82)