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1064 Williams Rd j 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-.1 68) Permit Number Name /�i.<� `'� � � ' ff✓ter/ Date Al-� 32 Location G(1 �; i/ 1` : %��i /r / �r % Subdivision Name Lot No. Sec. or Block No. Lot Size Y %��` House v Mobile Home _ Business Speculation No. Bedrooms `� No. Baths No. in Family -- _ Garbage Disposal YES ❑ NO,;d Specifications for System: Auto Dish Washer YESNO ❑ 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. 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. 4 Final Installation Diagram: System Installed by /7)� Certificate of Completion �� L/ 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. 071A 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 UNTILIMPROV x1�ENT PERMIT HAS BEEN ISSUED. �I. Home Phone 9 F /9 1. Permit Requested By Business Phone 2. Address /,z /4&-'Z 2G 2 Cz-O- -�`-u-, �i �7oa 6 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 Industry Other b) Number of people S 6. a) If house or mobile home, state size of home and number of rooms. House Dimensions :Y!g X Z� .Bed Rooms—Bath RoomsDen 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_ washing machine dishwasher sinks Z 8. a) Type water supply: Public '� Private Community b) Has the water supply system been approved? Yes No 9. a) Property Dimensions 30 X f? 9 b) Land area designated to building site c) Sewage Disposal Contractor l 10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve? /✓ d What type? This is to certify that the information is correct to the best of my knowledge. Date dwner Signature OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS r Allow 5 days for processing ftnDtr_.ecttio-ns to property: 0 � � -70k s DCHD(6-82) , DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section. P. O. Box 665 Mocksville, N.C. 27028 SOIL/SITE EVALUATION Name w ir Date ��! Address Lot Size / 7 2A FACTORS AREA 1 AREA 2 AREA 3 AREA 4 1) Topography/Landscape Position S S S PS PS PS Pui U U U 2) Soil Texture (12-36 in.) Sandy, ��SS--,,.�� S S S Loamy, Clayey, (note 2:1 Clay) (PSS PS PS PS U U U 3) Soil Structure (12-36 in.) S S S Clayey Soils PS PS PS U U U 4) Soil Depth (inches) S S S PS PS PS U U U 5) Soil Drainage: Internal S S S PS PS PS U U U External S S S PS PS PS U U U 6) Restrictive Horizons 7) Available Space `s S S S g 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—ProvisionaliSuitabl Recommendations/Comments: Described byTitle ��"' Date 2h SITE DIAGRAM L�7 DCHD(6-82)