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137 Williams Way (2) 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 Namer,yL2),•/r. Date ?2:7 Location ��' ,� - r ',�t i /6 A-�/A Subdivision Name Lot No. Sec. or Block No. Lot Size 1,2 X1 1-e'«Z- House Mobile Home _ Business Speculation No. Bedrooms No. Baths No. in Family _ Garbage Disposal YES ❑ NO 21- Specifications for System: - Auto Dish Washer YES ❑ NO Auto Wash Machine YES p' NO ❑ �- o?,,f. - ��x e: � <<- Type Water Supply *This permit Void if sewage system described below is not installed within 36 months from date of issue. if 11 Improvements permit by *Contact a representative of the Davie County Health Department for final inspectidn, 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 Z - l �IL � ��'L � C1 kA - ZZ - � Certificate of Completion r ` ° Date *The signing of this certificate shall indicate that the system described love 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. APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT Davie County Health Department Environmental Health Section P. 0. Box 665 Mocksville, N.C. 27028 CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED. Home Phone 9Q4 $Ba q 1. Permit Requested By Sam u o-l ('-Qo `t c, c DRU Business Phone `7�� ` L{G 0 44 2. Address A 019 M 6ck a 0 3. Property Owner if Different than Above W t tQ M C.On LOA SDR� Address a m� 4. Permit To: a) Install Alter Repair b) Privy Conventional Other Type Ground Absorption c) Sub-Division Sec. Lot Np 5. System used to serve what type facility: House Mobile HomeY___�LBusiness — b) �` b) Number of people �W 4 IndustryOther 6. a) If house or mobile home, state size of home and number of rooms. House Dimensions )q " -1 b Bed RoomsUP—() 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 �W D urinals garbage disposal lavatory. D showers f WII o washing machine 30 V)f- , sinks i �< 8. a) Type water supply: Public Private Community C-OWK4y"td) b) Has the water supply system been approved? Yes t/ No 9. a) Property Dimensions I a V'qac.12el5 b) Land area designated to building site c) Sewage Disposal Contractor HatVf' Y)D+ CoY1-'f'a e Corifuct ORye+ . 10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve? N What type? This is to certify that the information is correct to the best of my knowledge. - q Date Owner Signature OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS Allow 5 days for processing Directions to property: }�i3hway 'jDI , h0jfW0.y bv_twe y) Wildlife, baG-±Iandioq and l7 uto-km . plu eek -- on ACR(r s BIZ O,m h We_ 0� y Vo e-I of n. +ovictads FoRk ,9 9 � DCHD(6-82) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. 0. Box 665 Mocksville, N.C. 27028 SOIL/SITE EVALUATION Name s!1"i ��� Date 4�-i 3-P 3 - Address Lot Size /Z 'lz-Oc,*'`- FACTORS AREA 1 AREA 2 AREA 3 AREA 4 1) Topography/Landscape Position S S S S <V!) PS PS 2) Soil Texture (12-36 in.) Sandy, S S S S Loamy, Clayey, (note 2:1 Clay) mac-, -4m> PS PS U U U U 3) Soil Structure (12-36 in.) S S S S Clayey Soils e!T-Z:> ® PS PS U U U U 4) Soil Depth (inches) S S S S �-� <Tm--> PS PS U U U U 5) Soil Drainage: Internal S S S S PS PS U U U U External S S S S PS PS U U U U 6) Restrictive Horizons 7) Available Space S S S S PS PS U U U U 8) Other (Specify) S S S S PS, PS PS PS U U U U 9) Site Classification �-S Zj- U—UNSUITABLE S—SUITABLE � Ily Suitable Recommendations/Comments: '^ e ' Described by q-•m�-� Title Ccr�c�c,.-tom Date SITE DIAGRAM lJ1�2' c Zd L V DCHD(6-82) QbV I l� " DAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION *Note: Issued in Compliance with G.S. of North Carolina Chapter 130—Article 13c. Permit Number Name Date i Location Subdivision Name Lot No. Sec. or Block No. Lot Size House Mobile Home — Business Speculation .No. Bedrooms No. Baths No. in Family Garbage Disposal YES ❑ NO ❑' Specifications for System: Auto Dish Washer YES ❑ NO ❑ 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. i .Improvements permit by *Contact a representative of the Davie Cou ty 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 ompletion. Telephone Number: 704,634-5985. Final Installation Diagram: System Installed by 'oJ7 Certificate of Completion Date *The signing of this certificate shall indicate that the.system described Bove 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.