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118 Dartmouth Ln (2) 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-.1968) Permit Number Name Jd: . , frr Date Location Subdivision Name Lot No. Sec. or Block No. Lot Size `%! House ... Mobile Home 2 Business Speculation No. Bedrooms No. Baths _ No. in Family Garbage Disposal YES ❑ NO (D Specifications for System: Auto Dish Washer YES NO ❑ f- > Auto Wash Machine YES NO ❑ � ' `` "`�'` �.,f. ;v Type Water Supply i� *This permit Void if sewage system described betdw�is not installed within 36 months from date of issue. f t 1 1 a I 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'a — S Ix t I ��t I 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 Pld 4.5 R 0. Box 665 Mocksville, N.C. 27028 CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED. Home Phone 9/ 1. Permit Requeste By a h e _ w e, f Business Phone 7o y 6 3 9' -3 S6/ 2. Address 3. Property Owner if Different than Above Vj rr o P Address 6 n K 3.5-8 Ile 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 HomeB�s IndustryOther b) Number of people 3 6. a) If house or mobile home, state size of home and number of rooms. House Dimensions Z x -Z Bed Rooms—Bath RoomsDen 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 2 washing machine dishwasher sinks 3 8. a) Type water supply: Public a 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? A10 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: V17Ile r 0QC/ )7- 7- © nom W1, orV I, 3 le _5 l a S e o &.,7 L e 7' e area b c L, : .� LjOKS e O DCHD(6-82) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section R 0. Box 665 Mocksville, N.C. 27028 SOIL/SITE EVALUATION �, Date Name � Address Lot Size �� FACTORS AREA 1 AREA 2 AREA 3 AREA 4 1) Topography/Landscape Position S P � C U U 2) Soil Texture (12-36 in.) Sandy, S S S S Loamy, Clayey, (note 2:1 Clay) P q, PS U 3) Soil Structure (12-36 in.) S S Clayey Soils PS PS U 4) Soil Depth (inches) S S S S PS O ® LTJ U U 5) Soil Drainage: Internal S S S ,1Ste�.. P5, � �.% (% �� U External S S S S PS PS PS PS U U U U 4 6) Restrictive Horizons 7) Available Space S S. S S PS PS PS PS U U U U 8) Other (Specify) S PS PS PS PS U U U U 9) Site Classification S /" ' U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable Recommendations/Comments: Described byTitle _ �� Date SITE DIAGRAM DCHD(6.82)