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180 Legion Cemetery St 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 y1934-.1968) Permit Number .Name f`ri �rl� . . �f - =t-' , �` ./ � Date Location r' Subdivision Name Lot No. Sec. or Block No. Lot Size House Mobile Home _ Business _— Speculation No. Bedrooms No. Baths _,Z _ No. in Family Garbe9e Disposal YES.,E] NO g- 1 / Specifications fgr_System: • , {`• � Auto Dish Washer YES NO ❑ �' : / r ;i %,� ;,! Auto Wash Machine YES NO -❑ C= Type Water Supply . l *This permit Void if sewage system described..below is not installed within 36 months from date of issue. 3&17D X r ,- Improvements permit by a, `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 I of completion. Telephone Number: 704-634-5985. Final Installation Diagram: System Installed by . 1 � 1 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. DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Box 665 Mocksville, N.C. 27028 SOIL/SITE EVALUATION Name �UDate �« Address Lot Size FACTORS AREA 1 AREA 2 AREA 3 AREA 4 1) Topography/Landscape Position S S S PS PS PS U U 2) Soil Texture (12-36 in.) Sandy, S S S S Loamy, Clayey, (note 2:1 Clay) PS PS PS © & U U 3) Soil Structure (12-36 in.) S S S S Clayey SoilsS PS PS U U 4) Soil Depth (inches) S S S S P PS PS U U 5) Soil Drainage: Internal S S S S PS PS PS U U External S S S PS PS PS U U 6) Restrictive Horizons 7) Available Space S S S PS S PS PS UU U U U VS S 8) Other (Specify) P01 S PS PS PS U U U U 9) Site Classification ' 4'S 1 ls, 5 U—UNSUIT LE S—SUITABLE PS—Provisionally Suitable Recommendations/Comments: TZ--0 Described by '�' G / Title " ' Date SITE DIAGRAM DCHD(6-82) s+ APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT Davie County Health Department Environmental Health Section P. O. Box 665 Mocksville, N.C. 27028 CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED. Home Phone 1. Permit Requested By1Pn�t l�aer Business Phone – 2. Address OO 6151- 7A , ­7�11 oma70Zq 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 No. 5. System used to serve what type facility: Housed Mobile Home Business Industry Other. b) Number of people 3 6. a) If house or mobile home, state size of home and number of rooms. House Dimensions a`l x 3.2 Bed Rooms_nL'—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 sinks 8. a) Type water supply: Public—I-' Private Community b) Has the water supply system been approved? Yes No 9. a) Property Dimensions & a C'At" b) Land area designated to building site G�� c) Sewage Disposal Contractor AIC L Z) 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 bes of my:P"ed�/_ IPG Jarr'� Date Owner Signature OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS Allow 5 days for processing Directions to property: DCHD(6-82) /