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159 Whetstone Dr DAVIE COUNTY HEALTH DEPARTMENT 4 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 %, -f� �;�`4.: /: Date ��� /�'% Est^r .3329 Location / '>— i it r i `.�f ?�: Z �, �� ✓ -- _ Subdivision Name Lot No. Sec. or Block No. Lot Size House Mobile Home !ice Business _— Speculation No. Bedrooms 2 No. Baths — No. in Family J— Garbage Disposal YES ❑ NO ©/ Specifications for System: Auto Dish Washer YES NO ❑ / ,c.' ' Auto Wash Machine YES NO ❑ Type Water Supply _— *This permit Void if sewage system described below is not installed within 36 months from date of issue. r t Improvements permit b —! Cr *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 CO pleti n Date *The signing of this certificate shall indicate that the sye/temescribed above has been installed in compliance with the standards set forth in the above regulation, but shall in NO ay be taken as a guarantee that the system will function satisfactorily for any given period of time. 3 APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT y�� Davie County Health Department 1 � Environmental Health Section P. O. Box 665 - Mocksville, N.C. 27028 CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED. wv� Home Phone 1. Permit Requested By ` ` ` Business Phone 2. Address 3. Property Owner if Differentthan Above Zi1rne Address 4. Permit To: a) InstallX 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 Homed Business IndustryOther b) Number of people -3 6. a) If house or mobile home, state size of home and number of rooms. House Dimensions 10\445 m6bf(e_ Nor -p— Bed Rooms.—Bath Rooms Den w/Closet No 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 X garbage disposal lavatory showers washing machine x dishwasher X sinks Znu 1p_ 1ti Ka iJ 8. a) Type water supply: Public Private—_X_Community b) Has the water supply system been approved? Yeses No 9. a) Property Dimensions :? AcCeS b) Land area designated to building site O� c) Sewage Disposal Contractor 10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve? y� What type? This is to certify that the information is correct to the best of my knowledge. '� - 4 - Date Owner Signature OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS Allow 5 days for processing Directions to property: DCHD(6-82) -` DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section R 0. Box 665 Mocksville, N.C. 27028 C. SOIL/SITE EVALUATION Names x � Date Address Lot Size FACTORS AREA 1 AREA 2 AREA 3 AREA 4 1) Topography/Landscape Position S® S PS PS U U 2) Soil Texture (12-36 in.) Sandy, S S S Loamy, Clayey, (note 2:1 Clay) PS PS PS PS U U U U 3) Soil Structure (12-36 in.) S S Clayey Soils *LU PS PS PS U U 4) Soil Depth (inches) S S S PS PS U U U 5) Soil Drainage: Internal S S� S S PS PS U U U U External S S S PS PS 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 c U U 9) Site Classification -` J U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable Recommendations/Comments: Described by ` Title Date SITE DIAGRAM DCHD(6-82) _