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451 Sparks Rd �f. 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 /2�Nrtc;, fil dins 'voj Date .� - 20 ��/ �.x"y i4-10 l2 Location i�, z� o ���E 7. -f-! I 11 fro r CA.- ��r 7' c�' 1/,1.G s l ,rL•� ! E111 T 611- Cs Tc /ys ilN�� ✓�. c f < r /!a ,::.� < ,r f F Subdivision Name Lot No. - Sec. or Block No. Lot Size 17, House Mobile Home _ Business -- Speculation No. Bedrooms -3 No. Baths �Z No. in Family Garbage Disposal . YES ❑ NO {- Specifications for System: ,wooG- Auto Dish Washer YESNO Auto Wash Machine YES �j E]NO ❑ 3C70 n x Type Water Supply --- *This permit Void if sewage system described below is not installed within 36 months from date of issue. 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. 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 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. 0. Box 665 Mocksville, N.C. 27028 SOIL/SITE EVALUATION Name QoNA+-� �c�s-rary Date Address IZI Soy 3 S2- / Lot Size /7A- Ac ecx A D VAw6f— Nc- 2.7a0 4 -FACTORS AREA 1 AREA 2 AREA 3 AREA 4 1) Topography/Landscape Position � S S S ( PSS PS PS U U 2) Soil Texture (12-36 in.) Sandy, S S S S Loamy, Clayey, (note 2:1 Clay) PS PS US US 3) Soil Structure (12-36 in.) S S S Clayey Soils -Tpb"� PS PS U U U 4) Soil Depth (inches) SS S P _( PS PS U U 5) Soil Drainage: Internal S S S P PS PS U U External S S S PS PS Tj 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—UNSUITABLE S—SUITABLE PS—Provisionally Suitable Recommendations/Comments: Described by Title fi'''t'"' rDate SITE DIAGRAM �. DCHD(6-82), - APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT Davie County Health Department Environmental Health Section 3' R O. Box 665 Mocksville, N.C. 27028 CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED. Home Phone 1. Permit Reed By if Business Phone 2. Address OL 3. Property Ow er if Different a Above Address eid 00 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 Business IndustryOther b) Number of people 6. a) If house or mobile home, state size of home and number of rooms. House Dimensions /2 X Bed Rooms ---? Bath Rooms 2—' 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 showers l washing machine dishwasher © sinks �- 8. a) Type water supply: Public Private_ Community b) Has the water supply syste,w been approved? Yes No 9. a) Property Dimension b) Land area designated to building site c) Sewage Disposal Contractorw� 10. Do you anticipate any ad itions r expansions of the f cility th' sewage ystem is intend0d to serve? -s What ty e? o�-s �' �� This is to certify that the information is correct to the best off my knowledge. e 0 Ze Date Owner Signature OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS Allow 5 days for processing Directions to property: , /-0 Al fe Fa Y' �` Fs 0 DCHD(6-82) } DAVIE COUNTY HEALTH DEPART1113ENT SITE EVALUATION CONSENT FORM INSTRUCTIONS/PREREQUISTES 1. Complete the form below and return it to the Davie Co. Health Department. 2. Along with the form, remit the amount due as shown on enclosed statement. 3. Carefully follow the procedures as outlined in the enclosed "Information Bulletin". 4. Notify Health Department upon completion of item number 3. NOTE: ALL THE ABOVE MUST BE DONE BEFORE A SANITARIAN WILL BE ABLE TO BEGIN THE REQUESTED EVALUATION. DETACH HERE AND RETURN TO THE(DAVIE COMITY HEALTH DEPARTMENT,P.O. BOX 57) (HOCKSVILLE, N.C. 27028) DAVIE COUNTY HEALTH DEPARTYXNT SITE EVALUATION CONSENT FORM LOCATION OF PROOPERTY• �®� DATE RECEIVED //�.o.✓ �'p% �E y (office use only) eaWee 7 m S . .�.¢ 3 —Y—F y�eess( no-t (1.) I am the owner of the above described property. yes no (2.) I am not the owner of the above described property, however, I j certify that I have consent from ,owner to ii owner's name obtain a site evaluation by the health Department for the purpose of determining the suitability for a ground absorption sewage disposal system. yes no (3.) I hereby give consent to the authorized representative of the ! Davie County Health Department to enter upon the above described _ l property and conduct all testing procedures necessary to determine its suitability for a ground absorption sewage disposal system. DATE SIGNATURE (4.) I hereby authorize the Davie County Health Department to release site evaluation results from the above described property to the following: IT Owner Only t3 Owner's designated representative C51— Anyone requesting results DATE [`1 only those listed below /0;� SIGNATURE