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933 Hwy 64W (2) a t .-4 DAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION ,NOTE:Issued in Compliance With Article 11 of G.S.Chapter 130a Sanitary Sewage Systems Permit. Number Name I^.=a /e /Z 26'22 tf�%r,Z �/� Date N2 5858 /'�' J Location /''1;1 /r,�;✓ �� / ` ieT Subdivision Name Lot No. Sec..or Block No. Lot SizeHouse /�� 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 Gi lo,Type Water Supply 9 `This permit Void if sewage system described below is not installed within 5 years from date of issue. This permit is subject to revocation if site plans or the intended use change. l=s 1 s ry h, w F � x \ 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— ' " T V ! - � Certificate of Completion Date!oDate '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. N' APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT Davie County Health Department ` Environmental Health Section D FEB � 9 P. 0. Box 665 Mocksville, NC 27028 RECEIVE 1 . Application/Permit Requested By T.g m e c E S 2 Mailing Address ef e /' Bcsx /2— A2"_ �'.S iJi del /�Gi X 7028 Home Phone Business Phones 2. Name on Permit if Different than Above SA'" P 3. Property Owner if Different than Above _q'9 m I-- 4. rte4. Application/Permit For : 0 General Evaluation 4?0'b"/Tank Installation 5. System to Serve: 43-.*'H'ouse u Mobile Home 0 Business L Industry - Other 0 Unknown 6. If house, mobile home: Subdivision Sec. Lot# No. of People Dwelling Dimensions No. of Bedrooms 1 Basement/Plumbing No. of Bathrooms / Basement/No Plumbing 0 Washing Machine 0 Dishwasher 0 Garbage Disposai 7. If business, industry, other: Specify type No. of People Served No. of Sinks No. of Commodes No. of Urinals No. of Lavatories No. of Water Coolers No. of Showers 8. Type of water supply: 0 Public ''Private 0 Community 9. Property Dimensions _J 10. Sewage Disposal Contractor 11 . Do you anticipate additions/expansions of the facility this system is intended to serve? []- Yes &1vo If yes, what type? *NOTE: Improvements Permits shall be valid for a period of 5 years from date issued. Improvements Permits are subject to revocation, if site plans or the intended use change . Effective October 1, 1989. This is to certify that the information provided is correct to the best of my knowledge, and I understand I am responsible for all charges incurred from this application. Date Signat re Directions to Property : hiS tS Rn o l� �c � © 4s e, trto v 7,e,71 / liv:/¢o c, yy ,? - .0 1'2 �e m 0 17 DCHD (10-89) • DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section. P. O. Box 665 Mocksville, N.C. 27028 . SOIL/SITE EVALUATION \ Name ,n VOA Date Address Lot Size FACTORS AREA 1 AREA 2 AREA 3 AREA 4 1) Topography/Landscape Position11 S -7 a .Q S PS PS PS U U U U 2) Soil Texture (12-36 in.) Sandy, S S S S Loamy, Clayey, (note 2:1 Clay) U U U U 3) Soil Structure (12-36 in.) S S S S Clayey Soils " CE35� U U U 4) Soil Depth (inches) S P3 U U U 5) Soil Drainage: Internal S _-- P P U U U U External SS U U U U 6) Restrictive Horizons - 7) Available Space 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 - t�--�• - U—UNSUITABLE S—SUITABLE �PS_Provisionaliy Suitable Recommendations/Comments: Described by ,��,/�1, Title _�%a Date SITE DIAGRAM l DCHD(6-82)