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4231 Hwy 601N DAVIE COUNTY HEALTH DEPARTMENT �v 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 ,? �SAnI ,> Date 1q, g 7 e �-Q 3668 Location (n- t hi_ C� ,, L4�f'i 7��i-gin 'zj j)t?syE-L-0,V /�'t"i rc ©c. ) �Q Subdivision Name Lot No. Sec. or Block No. Lot Size 1, 32 A=-- House "'� Mobile Home _ Business _— Speculation No. Bedrooms '- No. Baths - No. in Family _ Garbage Disposal YES ❑ NO Er Specifications for System: /Oooqc��N f�N� Auto Dish Washer YES NO 0 Auto Wash Machine YES NO -p 00 Type Water Supply n �-�, _ 1 -A,Crx Z *This permit Void if sewage sys rn described below is not installed within 36 months from date of-issue. S� o rr �z 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. 42 Final Installation Diagram: System Installed by ham_ y j 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 R O. Box 665 Mocksville, N.C. 27028 SOIL/SITE EVALUATION Name Date Address ' 16cC 82 —� Lot Size A— /Ll s vr�c /Ve- FACTORS AREA 1 AREA 2 AREA 3 AREA 4 1) Topography/Landscape Position (9) 9) ® TS PS PS PS U U U U 2) Soil Texture (12-36 in.) Sandy, S S � j� Loamy, Clayey, (note 2:1 Clay) © q CJ LJ U 3) Soil Structure (12-36 in.) S S S S Clayey Soils (a) ® (prj�) PS U U U 4) Soil Depth (inches) S S S S © ® PS PS U U U U 5),Soil Drainage: Internal S P 6 0 U U U External S© U U U U 6) Restrictive Horizons 7) Available Space © Q 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: x x ME46 .Z .41 Described by Title Dateg SITE DIAGRAM � ,-r o P $ o P Kt 1% DCHD(6-82) 7- APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT Davie County Health Department Environmental Health Section P. O. Box 665 Mocksville, N.C. 27028 CONSTRUCTION SHALL'NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED. Home Phone `� /`j -99g -,3354 1. Permit Requested By Business Phone 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-Division Sec Lot No. 5. System used to serve.what type facility: House Mobile Home Business IndustryOther b) Number of people !!I- 6. a) If house or mobile home, state ize of 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 2- urinals garbage disposal lavatory. 2- showers %L washing machine Z dishwasher sinks 2 8. a) Type water supply: Public ✓ Private Community b) Has the water supply syst m been approved.? Y s No 9. a) Property Dimensions b) Land area designated to building site a 9 c) Sewage Disposal Contractor 10. Do you anticipate any additions or expansions of the facility this sewa a system is intended to serve? What type? AA` u ./ � . TA is to c rtify that the information is correct to the best of my knowledge. Date Owner Signature OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS Allow 5 days for processing Directions to property: , .'PLa-7,09 D � �- u^�. 1.3 9 AC. P-A M r- �F2AME 1321 Cie_ 3,_p m , Wm iZ 'DA VIE .P 5CH 90 L- I N TO AD�►N , t$1 rn � ,-��L1' C� r� G�C2t�� DCHD(6-62) 7 , � � V1 �� -a DAVIE COUNTY HEALTH DEPARTMENT SITE EVALUATIO14 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 COUNTY HEALTH DEPARTMENT,P.O. BOX 57) (MOCKSVILLE, N.C. 27028) DAVIE COUNTY HEALTH DEPARTMENT SITE EVALUATION CONSENT FORM ELOCA7MII OF PROPERTY: !9''� D/�/ DATE RECEIVED Ci� 4 (offiQe use dnly) 1aZ�L des not (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.) 1 hereby give consent to the authorized representative of the II Davie County Health Department to enter upon the above described L._.i property and conduct all testing procedures necessary to determine its suitability for a ground absorption sewage disposal system. DATE SIGNATURE V (4.) I hereby authorize the Davie County Health Department to release site evaluation results from the above described property to the following: 9 Owner Only Owner's designated representative 0 Anyone requesting results TE VC Only those listed below ml& SIGNATURE