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261 Rag Rd v -4W _ �:.. Y - . .{'�,�-' DAVIE, COUNTY- HEALTH' DEPARTMENT !i IMPROVEMENTS; PERMIT AND CERTIFICATE OF COMPLETION *NOTE: Issued in Compliance with G.S. of North Carolina Chapter 130 Article 13c 1 Sewage Treatment and Displh osal Rules (10 NCAC 10A..1934-.1968) Permit -Number Name 3N:;�v S 'e_F. 1 f� � Date 4435 - � it ` .� • Location . ► -:-, , -r 'T Subdivision Name Lot No. Sec. or Block No. Lot Size Z x Mobile Home Business _ Speculation/ No. Bedrooms — No. Baths �` �' No. in Family -� 11 . Garbage Disposal YES ,0,; No Ed1 Specifications for System: Auto Dish Washer YES p- NO 1� Auto Wash Machine YES NO Type Water. Supply *This permit Void if sewage system described below isnot installed within 36 months from date of issue. . n ; ISI ' ;�. ' ,` � -- \ •.�r.'"E�r'].. •` ` 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. Tele hone Number: 704-634-5985. - s Final Installation Diagram: �� S stem I •talled by L ' a :/VW A. - � .Certificate of Completion. _ Date *The signing of thiscertificateshall 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 as a guarantee that the system will function satisfactorily for any given period of time II. APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT Davie County Health Department, ,. Environmental Health Section P. 0. Box 665 Mocksville, N.C. 27028 119&0 CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED. Home Phone 1779-31066 1. Permit Requested By A U-r Business Phone 3 y- 3 ya P 2. Address ) cosi TL- 3. Property Owner if Different than Above Address 4. Permit To: a) Installer Alter Repair b) Privy Conventional_r--""Other Type Ground Absorption c) Sub-Division Sec. Lot No. 5. System used to serve what type facility: House ✓Mobile Home Business IndustryOther b) Number of people—1 6. a) If house or-mobile home, state size gf home.and number of rooms. House Dimensions 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 -3 urinals garbage disposal lavatory 3 showers washing machine dishwasher I sinks 8. a) Type water supply: Publics Private Community b) Has the water supply system been approved? Yes No 9. a) Property Dimensions gs__�--— �` ado 2 7 b) Land area designated to building site a 12 a cl e c) Sewage Disposal Contractor 'A e Rc-) 77-C 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 best of my knowledge. Ll- Date Owner Sig ature OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS Allow 5 days for processing Directions to property: U- to D l ,©a-t_� on. Ike) - ` d tk , DCHD(6-82) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section R 0. Box 665 Mocksville, N.C. 27028 SOIL/SITE EVALUATION Name David and Pam Speer Date S" Z Address _.Rt. 8, Box 276 Lot Size 200 x 297 Mocksville FACTORS AREA 1 AREA 2 AREA 3 AREA 4 1) Topography/Landscape Position S S S S PS U � U 2) Soil Texture (12-36 in.) Sandy, S S S Loamy, Clayey, (note 2:1 Clay) ® (2k PS U U � U 3) Soil Structure (12-36 in.) S �OU AU S Clayey Soils PS U 4) Soil Depth (inches) S S S OjJ PS U U U 5) Soil Drainage: Internal S S S S eca__> KETP t� PS U U U U External S_ 4P, S opPS 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 11_� 00-5 U—UNSUITABLE S—SUITABLE —Provisionally Suitable Recommendations/Comments: Shw/r a SS r,/• 3 .ado• �� Described by Q• r"i^-�'' Title Sanitarian Date SITE DIAGRAM 4J :" �14 DCHD(6-82)