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217 Dulin Rd DAVIE COUNTY HEALTH DEPARTMENT ,+ IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION *-Note: Issued iri Compliance with G.S. of North Carolina Chapter 130—Article 13c. Permit Number Name a c F Date Location 15-v _ i �� �" u.1' ,. ?�, >.0 - , ,r ,:I ;� .,�• ,.. i�4:} ,:, 1 �_. Subdivision Name Lot No. Sec. or Block No. i Lot Size 147 House Mobile Home _ Business Speculation No. Bedrooms ' No. Baths No. in Family 3 Garbage Disposal YES ❑ NO p' Specifications for System: �,;, ��<..f• 7 V- Auto Dish Washer YES ❑ NO p-- Auto Wash Machine YES ❑--NO ❑ �' �'"1 - - 'D Xi t Type Water Supply C o i *This permit Void if sewag�m-described-bet w is not installed within 36 months from date of issue. ,.n N-\ 01 0 1 Improvements permit by,- 0 *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 r�'� 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 R O. Box 665 Mocksville, N.C. 27028 SOIL/SITE EVALUATION Name VeUE lec Date Address ,��• 2 i3`� ��� Lot Size iSa X�9j 20 2e FACTORS AREA 1 AREA 2 AREA 3 AREA 4s 1) Topography/Landscape Position S SS S P dp 5 U U U 2) Soil Texture (12-36 in.) Sandy, S S S �S Loamy, Clayey, (note 2:1 Clay) PS U U 3) Soil Structure (12-36 in.) S S S Clayey Soils P ® ® FS U U 4) Soil Depth (inches) $ S S PS 0-19 el�s U 5) Soil Drainage: Internal SS S S s P © (TK:> External S S '&& ) P5 dp 9) U U U 6) Restrictive Horizons �Y`' ?��'� SeI `SA��. SHPQ� 111CI� fib` ,AR K �r 7) Available Space S S. S S p PS PS 5 U U 8) Other (Specify) S S S S PS PS PS PS U I U U U 9) Site Classification u5 f �J U—UNSUITABLE S—SUITABLE C PS—Provisionally Suitable Recommendations/Comments: i Described by Q rn&A-ja Title ( • �� &nd'o"* Date SITE DIAGRAM t ( i wSLy ,. v DCHD(6-82) � I , I\ v APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT t( 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 9V-.99Q S 1. Permit Requested By ` YC Ve-/l �� 4., Business Phone 2. Address "t 21 160 4.S�fS ZVOe (5 v j Ile A C 0 a, 3. Property Owner if Different than Above SFf(n eS �_De k Address 4. Permit To: a) Installl-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 IndustryOther b) Number of people 3 6. a).If house or mobile home, state size of home and number of rooms. House Dimensions 16 X8 ' Bed Rooms 3 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 1 urinals garbage disposal lavatoryshowers washing machine dishwasher sinks 1 8. a) Type water supply: Public,—Private Community b) Has the water supply system been approved? Yes No 9. a) Property Dimensions 1 SO J Y 3 7,R' X lSO X 3 9,3 asp b) Land area designated to building site c) Sewage Disposal Contractor kshi j 411,:s- 10. 11,s 10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve? 0 _ What type? This is to certify that the information is correct to the best of my knowledge. 41) Date Owner Signature OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS Allow 5 days for processing Directions to property: }� f J e� o h v �o ci d -�QSf 9,Ld ho u C'_ 0.1 DCHD(6-82)