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201 Major Rd (3) 1 �•�'=' 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 j Name Date T' a �".' / i Location ;i� .: �` ! �r %_. , , �' — �,. ✓ ,.. Subdivision Name Lot No. Sec. or Block No.' Lot Si 6 House Mobile Home — Business Speculation No. Bedrooms No. Baths —2 No. in Family Garbage Disposal YES ❑ NO E],,-- Specifications for System: Auto Dish Washer YES [3 NO ❑ Auto Wash Machine YES Eh NO ❑ Type Water Supply 'This permit Void if sewage system described below is not installed within 36 months from date of issue. L-� 1 jV Improvements permit by *Contact a representative of the avD i� County-H alth-Department for final inspection of this system between 8:30- 9:30 A.M. oryQ0--1-•:30-P.M. o do ay of/completion. :Telephone Number: 704-634-5985. Final Installation Diagram: System Installed by j _r . L j Certifica�te_of-Cnmpleti�� ` -� / Date *The signing of this certificat__ shall i'cate that the system described above has been installed in compliance with the standards set forth in the aboQve reg I tion, but shall in NO way be taken as a guarantee that the system will function satisfactorily for any given perioct`Zf�tme. DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section R O. Box 665 ' Mocksville, N.C. 27028 SOIL/SITE EVALUATION Name �/�y ZA�E Date �D _ 7 Address , - $� S/T Lot Size /?2fiCKs✓lcG� /'vim FACTORS AREA 1 AREA 2 AREA 3 AREA 4 1) Topography/Landscape Position 4 (�D 6> _ PS PS PS PS U U U U 2) Soil Texture (12-36 in.) Sandy, S S S S Loamy, Clayey, (note 2� PS �1 �Clmly) �.S c2ff5r ® d5 3) Soil Structure (12-36 in.) S S S S Clayey Soils ?F) a � 4) Soil Depth (inches) S f 'e S S or N S P 6-8 © 6-8 5) Soil Drainage: Internal S S S S U, 5U V External S S S S PS PS PS PS U U U U 6) Restrictive Horizons 7) Available Space � S. � 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: � e'4 nl Described by Ss Title Date �� 7�� Td, 2 SITE DIAGRAM 1 Wv v t DCHD(6-82) ` .• .r , 1 APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT Davie County Health Department Environmental Health Section P. O. Box 665 Mocksville, N.C. 27028 i CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED. Home Phone _ g9�—so77 1. Permit Requested By 0/+114 V A • 3,eA,1Z P Business Phone 7_73-22- o Cy�.�-�=P�-• 2. Address �T 3 BO 3. Property Owner if Different than Above Address 4. Permit To: a) Install_l�Alter Repair b) Privy Conventional Other Type Ground Absorption c) Sub-Division - Sec. Lot No. 5. System used to serve what type facility: House �IVlobile Home Business IndustryOther b) Number of people a 6. a) If house or mobile home, state size of home and number of rooms. House Dimensions— Bed imensions Bed Rooms '2- 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 l� washing machine / dishwasher sinks L 8. a) Type water supply: Public Private_c Community b) Has the water supply system been approved? Yes_1ZNo . 9. a) Property DimensionsX39 LZ X 660 b) Land area designated to building site apo t 6iJ X c) Sewage Disposal Contractor r,D,7_') W/qL X e A � 10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve? /y 0 What type? This is to certify that the information is correct to the best of my knowledge. Date 0 Owner Sign re OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS Allow 5 days for processing Directions to property: (1,e'0 /yloC1<59 SS - E f s T 7-0 /3,f 2-%i,�o.2� �D . ' T4c/1.✓ 2 i(9�IV T , BAL- T /�o.*D F::,T� �9M P 91) - To x/25 T -D/le i 1,9- G/- '7- G-), Z-.7� e, J-0 HAl DCHD(8-82)