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3532 Hwy 801N 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 �',1 4,:, v lv� r" Date ��' y 'd� pnl� 6 i Location Subdivision Name Lot No. Sec. or Block No. Lot Size I- - e . House Mobile Home — Business Speculation No. Bedrooms No. Baths No. in Family Garbage Disposal YES ❑ NO [- Specifications for System: Auto Dish Washer YES ❑ NO Auto Wash Machine YES ❑ NO Type Water Supply _ `This permit Void if sewage system described below isnot 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 Alk-Z' Z ' Q JO � 0 Certificate of Completion �, �'' 1 ��c� 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. w DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Box 665 Mocksville, N.C. 27028 SOIL/SITE EVALUATION Name 2°LAI,IL> wDate 16 g5/ Address Lot Size 34'e y' FACTORS AREEA^�,1 AREA 2 AREA 3 AREA 4 1) Topography/Landscape Position (9 I c8D S S PS PS PS PS U U U U 2) Soil Texture (12-36 in.) Sandy, S S S S Loamy, Clayey, (note 2:1 Clay) PS PS PS PS 0>. U U 3) Soil Structure (12-36 in.) S S S S Clayey Solis PS PS PS PS U U 4) Soil Depth (inches) S S S S PS PS PS U U 5) Soil Drainage: Internal S S S S PS PS PS PS U U U U External S S S S PS PS PS PS U U U U 6) Restrictive Horizons 7) Available Space S 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 (,A— U—UNSUITABLE S—SUITAB�LE _PS�—P visiona�IySable Recommendations/Co Described by- 4le Tom` Date/a `/6 SITE DIAGRAM L c zx a1,4A-1 JAII - DCHD(6-82) 2 mod �ND APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT Davie County Health Department Environmental Health Section R O. Box 665 Mocksville, N.C. 27028 CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED. Home Phone g4TOO 1. Permit Re uested By e4 Business Phone 2. Address 'Z '� 19Z-. MoLksvulls , - 2- oz 3. Property Owner if Different than Above Address 4. Permit To: a) Install-ZAlter Repair b) Privy Conventional-ZOther 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 Bed Rooms Bath Rooms Den w/Closet b) If Business, Industry or Other, State: Number of persons served What type business, etc. �'V ( ) J` Estimate amount of waste daily24 hours 7. Number and type of water-using fixtures: commodes urinals garbage disposal lavatory. ✓ showers washing machine dishwasher sinks 8. a) Type water supply: Public Private CommunityW 0 0" b) Has the water supply system been approved? Yes- No- 9. o 9. a) Property DimensionsS .9�9/QG��S a SFO /_� r !r/_©i b) Land area designated to building site /' � t �- 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. 112 Ely j57 Date Owner Signature OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS Allow 5 days for processing Directions to property: /ItGoft r a r-AWhr nhcfo r o 3 h`� DCHD(6-82) •�_ WC.