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692 Pine Ridge Rd (2) 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 Name Date Location �'" �/�, p'-Y, r ,� ' .L',��< �f ,/ ;%f: _�, r, Subdivision Name Lot No. Sec. or Block No. -Lot Size � '�''' House Mobile Home _t-r Business Speculation l No. Bedrooms No. Baths No. in Family _ Garbage Disposal YES ❑ NO,0 Specifications for System: Auto Dish Washer YES )❑ NO a _ Auto Wash Machine YES ❑ NO ❑ Type Water Supply 'This permit Void if sewage system described below is not-ins lied within 36 months-from date of issue. f I /. 4- j i 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. OZJ�?tip, Final Installation Diagram: System Installed by djU Certificate of Completion t Datel _ '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. �.5 ' APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT % 2 Davie County Health Department Environmental Health Section R 0. Box 665 Mocksville, N.C. 27028 CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED. Home Phone ��— `�c+� �? 47 1. Permit Reque ted B z 5 2, Business Phone 2. Address I C 2 �76 3. Property Owner if Different than Above Address 4. Permit To: a) Install r/ Alter Repair a� b) Privy Conventional Other Type Ground Absorption c) Sub-Division Seca Lot No. ;5,5. System used to serve what ty a facility: House Mobile Home Business - IndustryOther b) Number of people 6. a) If house or mobile home, state size of home and number of rooms. House Dimensions � � S Bed Rooms—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 g showers washing machine 7 `iIishwasher sinks / - 8. a) Type water:supply: Public Private ✓ Community b) Has the water supply system been approved? Yes ✓ No 9. a) Property Dimensions b) Land area designated to building site �2,oO X )-,o U ' c) Sewage Disposal Contractor 10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve?,. gC What type? This is to certify that the information is correct to the best of my knowledge. Date Own4r Signature OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS Allow 5 days for processing Directions to property: Pam A4c-- 2JZ, 5 DCHD(6-82) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Box 665 Mocksville, N.C. 27028 SOIL/SITE EVALUATION Name Date Address Lot Sizes�/9C FACTORS AREA 1 AREA 2 AREA 3 AREA 4 1) Topography/Landscape Position S S S PS (k') cff�) 2) Soil Texture (12-36 in.) Sandy, S S S S Loamy, Clayey, (note 2:1 Clay) USPS PS S ' 3) Soil Structure (12-36 in.) S C SS S S Clayey Soils PS PS PS 4) Soil Depth (inches) S S S S PS PS PS PS 5) Soil Drainage: Internal S S S S PS PS PSU External S S � <T> U U U 6) Restrictive Horizons 7) Available Space S S S S 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 U— S—SUITABLE PS—Provisionally Suitable Recommendations/Comments: Described by Date Title SITE DIAGRAM nn �� P2 DCHD(6-82) 3 DAVIE COUNTY HEALTH DEPARTMENT ` Environmental Health Section P. O. Box 665 Mocksville, N.C. 27028 gel SOIL/SITE EVALUATION Name /► s Date Address �� �1 �� Y '� Lot Size �� FACTORS AREA 1 AREA 2 AREA 3 AREA 4 1) Topography/Landscape Position S S S q � 15 2) Soil Texture (12-36 in.) Sandy, S S S S Loamy, Clayey, (note 2:1 Clay) © ® P U 3) Soil Structure (12-36 in.) - 10 S S ' S S Clayey Soils 05 . 1$ PS PS PS PS O Sip d (!q> a 4) Soil Depth (inches) lj3' f U S S S S PS PS © PS 5) Soil Drainage: Internal S S S S PS CCnT> PS PS External S S S 6) Restrictive Horizons 7) Available Space SSs� S. CUA' U'J U 8) Other (Specify) S S S S PS PS PS PS U U U U 9) Site Classification l/,-<.- Al <o� !�' _ �, /-U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable Recommendations/Comments: Described by Title Date 6 SITE DIAGRAM % BI � de VEV lie � y DCHD(6-82) J