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187 Levity Ln ' DAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION *Note: Nsued i Compliance with G.S. of North Carolina Chapter 130—Article 13c. Permit Number Location Subdivision Nar�e Lot No. Sec. or Block No. Lot Size 1 le f/ i1c re'� House Mobile Home Business -- Speculation No. Bedrooms -2- No. Baths No. in Family Garbage Dis al YES ;E] NO Specifications for System: /-0r:)0 9" Auto Dish Wash 3r YES E] N 0 Cj Type Water Su )ply *This permit Vo d if sewage system described below is not in-stalled-within.,36 months from date of issue. Li Improvements permit by *Contact a repr sentative 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 Certificate of Completion Date *The signing- of this certificate shall indicate that the system described above has been installed in compliance withthestandards s t forth in the above regulation, but shall in NO way be taken as a guarantee that the system will function aatiufoctod|yfo any given period of time. t' DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Box 665 Mocksville, N.C. 27028 SOIL/SITE EVALUATION Name KEITH Date Address 'CT' y 6"X /2S Lot Size—/ 4-14c' A4,d e.f vie-Lc- Aic 27o Z 9- FACTORS. AREA 1 AREA 2 AREA 3 AREA 4 1) Topography/Landscape Position © C SS S PS PS PS PS U U U U 2) Soil Texture - 6 in.) Sandy, S S Loamy aye ote 2:1 Clay) ( P5) PS PS U "� U U 3) Soil Structure (12-36 in.) S S Clayey Soils PS PS PS U U U 4) Soil Depth (inches) // S S ��, S PS PS U U U U 5) Soil Drainage: In ernalS S PS S PS PS U U U U E sternal S S QS PS PS PS U U U U 6) Restrictive Horiz ns I�iciv-Z 7) Available Space S S S S PS PS PS U U U U 8) Other (Specify) S S PS PS PS PS U U U U 9) Site Classification U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable z 0 Recommendations/ omments: I Described by � Title N� Date 174 2 SITE DIAGRAM DCHD(6-82) y =� •- ' APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT Davie County Health Department Environmental Health Section R 0. Box 665 Mocksville, N.C. 27028 i CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED. Home Phone 7e) 1P-1 1. Permit R que ted B Business Phone 9/9* 7.6& 9-66 2. Address 3. Property Owner if Different than Above Address 4. Permit To: a) Install Alter Repair b) Privy Conventional Other Type Ground Absorption c) Sub-DivisionSec. Lot NQ 5. System used to serve what type facility: H used Mob Home& Business — I dustry Other b) Number of people 6. a) If house or mobile hP_1&&V> , state size of home and number of rooms. ou a Dimens 3a r �/� 14 K 7X ed ooms—�Bath Rooms—,2Z Den w/Closet b) If Busir ess, Industry or Other, State: Number of persons served Wha type business, etc. Estimate amount of waste daily (24 hours) 7. Number and type of water-using fixtures: commodes 6/ -7— � ! urinals garbage disposal lavatory. showers -ZiZJ washing machin dishwasher sinks 0 8. a) Type water supply: Public Private Community b) Has th� water supply systembeena proved? Yes m No 9. a) Prope Dimensions ! e b) Land a ea designated to building site c) Sewag Disposal Contractor 10. Do you a ticipate 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 Vhe best of my knowledge. 14 r Date Owner Signature �WNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS 1 Allow 5 days for processing Directions toproperty: 19,E �1 GL DCH L� _