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615 Burton Rd Y- 1.i.v..:V ..k:r.a L'+-...':,x':iie'+,+{:iv. .. „ ✓ .Ku.. +. . ` e..r " .'i y DAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION `N9TE: Issued iii Compliance with G.S. of North Carolina Chapter 130 Article 13c r - Sewage Treatment and Disposal Rules (10 NCAC 10A :1934-.1968) Permit Number Name \1j .Q VV a k. Date ' �� -r(,=t NO o 4 GO Location _ ,� a ��`6 �� c'Z; YL Subdivision Name `\ � Lot'No. Sec. or Block No. Lot Size 1 _70 k ! n "" , ..House Mobile Home_`', Business Speculation No. Bedrooms c-Z No. Baths No. in Family Garbage Disposal YES ❑ NO [y Specifications for System: Auto Dish Washer., YES NO ❑ Auto Wash Machine YES ©,/-NO fl 1 t! Type Water Supply �?J': `�.. x , *This permit Void if sewage system described below is not installed within 36 months from date of issue. f 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 . Q dU t Ito 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. APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT Davie County Health Department Environmental Health Section R 0. Box 665 RECEIVED MAR .1. 5 N9 Mocksville, N.C. 27028 CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED. 1 Home Phone— 98" 3 0 1. Permit Requested ByTa' �nOr Business Phone 2. Address G 3. Property Owner if Q�Di""fferent than Above b ' Address'Fir. 3 box 48 Aa ro. Mc Agcy(o 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 Home Business IndustryOther b) Number of people 6. a�If house or mobile home, state size of home and number of rooms. House Dimensions" e X ,,1,, Bed Rooms—Bath Rooms Den w/Closet X14 b) If Business, Industry or Other, State: Number of persons served 1 What type business, etc. Estimate amount of waste daily (24 hours) 7. Number and type of water-using fixtures: commodes urinals 2? garbage disposal 10- lavatory showers a washing machine 1 dishwasher sinks a 8. a) Type water supply: Public Private—Community b) Has the water supply system been approved? Yeses No (wi) 9. a) Property Dimensions 0 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 correct to the best of my knowledge. Date Owner Signature OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS Allow 5 days for processing Directions to property: 7��e, 50 u and "aXX4. LTD "04J e` d ra �11,,,,•c� CIO 'Iez 4jLj-A_ t-r IL{- on -uraj roaA -144& ra-D alboLL+ 11/4- n6le s — 54Is 4a_k&a uK -b 4�je,:�+ os c!ou jD CIO u)ti DCHD(6-82) • DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section R O. Box 665 Mocksville, N.C. 27028 SOIL/SITE EVALUATION Name- - 1 9� P61ke_z, � �`� 0 Date - � 1 Address Qom^ Lot Size ! 7 y k 1 FACTORS AREA 1 AREA 2 AREA 3 AREA 4 1) Topography/Landscape Position - PS U U U 2) Soil Texture (12-36 in.) Sandy, S S Loamy, Clayey, (note 2:1 Clay) P P <�% `�- U 3) Soil Structure (12-36 in.) Clayey Soils dsij U U U U 4) Soil Depth (inches) S S S US US 5) Soil Drainage: Internal S c7kU External SS� S U 6) Restrictive Horizons 7) Available Space PS qps PS U . U 8) Other (Specify) S S S S PS PS PS PS 9) Site Classification - S U—UNSUITABLE S—SUITABLE PS— rovisionaliy Suitable Recommendations/Comments: Described by Title Date SITE DIAGRAM Ov> DCHD(6-82)