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706 Dulin Rd (2) DAVIE COUNTY HEALTH DEPARTMENT b�ff IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION' l j *NOTE: Issued in Compliance with G.S. of North Carolina Chapter 130 Article 13c 4 Sewage reatment.and)Disposal Rules (1'0 NCAC 10A .1934-.1968) Permit Number Name " lam .:<'>. r j�f,:r .(, Date ' .' �e^; 337 ',ocation ,�/ .� r' / ro �,✓ '/jam �, ;- " �r Subdivision Name Lot No. - Sec. or Block No. Lot Size House Mobile Home _ Business Speculation No. Bedrooms .-2 No. Baths No. in Family_Z _ Garbage Disposal YES ❑ NO ©-' Specifications for System: Auto Dish Washer YES NO '❑ Auto Wash Machine YY S 'j NO ❑ ' r / / //'�� "../<:;c'%.� _i,4�:f I—'r�,�✓'�i".:Cit %�'�!�� Type Water Supply ( C _ *This permit Void if sewage system desbri�ed belJw is not installed within 36 months from date of issue. l x1- trs'%f G `1 GL f r �- / i ,t Improvements permit by *Contact a representative of the Davie County Health Department for final inspection;,�f-�his system between 8:30- 9:30 A.M. or 1:00-1:30 P.M. 'ori.,day of completion. Telephone Number: 704-634-5985 Final Installation Diagram: System Installed b� L ,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 P. O. Box 665 Mocksville, N.C. 27028 SOIL/SITE EVALUATION Name Date Address Lot Size FACTORS AREA 1 AREA 2 AREA 3 AREA 4 1) Topography/Landscape Position S S S S PS A& 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 Soils PS PS PS PS © © U U 4) Soil Depth (inches) S S S S PS PS PS (�5 '<�� U U 5) Soil Drainage: Internal S S S S PS PS PS PS 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) PS PS PS PS Sita Classification U—UNSUITABLE S-SUITABLE PS—Provisionally Suitable Recommendations/Comments: T - Described by Title Date SITE DIAGRAM L DCHD(6-82) .. 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. 7 Home Phone 9qo CkrAaR 1. Permit Requested By Business Phone 2. Address 9-4 -6 69,r) 0-\QQ-KSu-t I le Y)Q- 3. Property Owner if Different than Above Address 4. Permit To: a) Install ter Repair b) Privy Conventional Other Type Ground Absorption c) Sub-Division Sec. Lot No. 5. System used to serve what type facility: House Mobile Home_i:::'_1Business IndustryOther b) Number of people 0n e- 6. a) If house or mobile home, state size of home and number of rooms. House Dimensions 12S i too Bed Rooms !A Bath Rooms t Den w/Close 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 O lavatory ( showers washing machine dishwasher sinks 8. a) Type water supply: Public Private Community b) Has the water supply system been approved? Yes No�� 9. a) Property Dimensions C�C{d�eS b) Land area designated to building site c) Sewage Disposal Contractor 10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve? '\d What type? This is to certify that the information is correct to the best of my knowledge. "r Date Owner Signature OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS Allow 5 days for processing Directions to property: Va Y\ '\Z CK V-"' -v- pry ea1 Ce DCHD(6-82)