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P3325 Riverview Rd i 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 ��, I�;P nit Date3 a, L 25 R-, Location t'•,1 - L ?��) l a^ K, / ,ko;E r, I 'll q,, I Vin, ..�► Subdivision Name Lot No. Sec. or Block No. Lot Size ? i Y CtfA Lv House Mobile Home Business _ Speculation No. Bedrooms �L- No. Baths No. in Family Garbage Disposal YES ❑ NO p- Specifications for System: 96e, pd, Auto Dish Washer YES ❑ NO E- Auto Wash Machine YES ❑' NO ❑ - 7'yX Type Water Supply v ic-1 1 __ST" L,1A /l,77;,e/P- *This permit Void if sewage system described below is not installed within 36 months from date of issue. 5, 7�/�7r N 4 Improvements permit by 1 J *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!1�9avd4 Certificate of Completion Date'" ! �J "The signing of this certificate shall indicate that the system describ d 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 r Nk�� Date ;7'``S' Addressy, Lot Size FACTORS AREA 1 AREA 2 AREA 3 AREA 4 1) Topography/Landscape Position S S S S PS PS U U 2) Soil Texture (12-36 in.) Sandy, SS S Loamy, Clayey, (note 2:1 Clay) <i!5:> A PS PS U U U U 3) Soil Structure (12-36 in.) S S Clayey Soils Ck C' PS PS U 1`jj U U 4) Soil Depth (inches) SS S co) PS PS PS U U U 5) Soil Drainage: Internal SS S PS PS U U U U External 4�5D S S PS PS PS PS U U U U 6) Restrictive Horizons 7) Available Space S S S © PS PS U 'p� U U 8) Other (Specify) S S S S PS PS PS PS U U U U 9) Site Classification / U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable Recommendations/Comments: , r Described by Title Date j SITE DIAGRAM DCHD(6-82) s g3 APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT ?� 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 3 (f-,5'O;�7 1. Permit Requested By / S�o re Business Phone Sam c 2. Address 7"• oc L� C 3. Property Owner if Different than Above Address 4. Permit To: a) Install Alter 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 Bs IndustryOther b) Number of people TwQ 6. a) If house or mobile home, state size of home and number of rooms. House Dimensions X �d Bed Rooms 2 Bath Rooms 2 Den w/Closet b) If Business, Indu§try 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 2 urinals 0 garbage disposal lavatory showers washing machine dishwasher sinks -� 8. a) Type water supply: Public Private 41"' Community b) Has the water supply system been approved? Yes `�No 9. a) Property Dimensions 2 .1,? ac. Ys 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? What type? This is to certify that the information is correct to the best of my knowl ge. ate 4bwner Signature OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS Allow 5 days for processing Directions to property: Q Q roX. /L rn•lcs or, DCHD(6-82)