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124 Old Mill Rd 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 S'lik oto F, yo6LEK.. Date 1�=2 � - a-%-{ 5 „ 56867 Location IJP 1EAs ZoLi-CT1k;F-iZA- iitAcr-s S��Znic,t_, �- T CToF SllatJ 'Fw-k t f(GUST 60 i?1G14T Subdivision Name Lot No. Sec. or Block No. Lot Size A r-- House Mobile Home.— Business Speculation No. Bedrooms _ No. Baths No. in Family Garbage Disposal YES ❑ NO ©, Specifications for System: a 11(1� Auto Dish Washer YES NO ❑ " 0 Auto Wash Machine YES NO ❑ � x 3 X 1, SraN� Type Water Supply 0LLr- *This permit Void if sewage system described below is not installed within 36 months from date of issue. i i 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 byAr r- YZ-AN500 ------------i C- — Certificate of Completion Se- Date 2� *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 NameS�i►N�tJ goC'Ly-%- Date $L2Z-Fs / Address�r 3 77-/3�77'A Lot Size FACTORS AREA 1 AREA 2 AREA 3 AREA 4 1) Topography/Landscape Position S S S S © PS PS PS U U U U 2) Soil Texture (12-36 in.) Sandy, S S S S Loamy, Clayey, (note 2:1 Clay) © PS PS PS U U U U 3) Soil Structure (12-36 in.) S S S S Clayey Soils PS PS PS U U U 4) Soil Depth (inches) S S S P PS PS PS U U U U 5) Soil Drainage: Internal S S S pg PS PS PS U U U External S S S PS PS PS U U 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 FS U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable Recommendations/Comments: -�`— Described by Title -S�¢-�tJi"')l�Lt/�-N Date �• ZZ•� SITE DIAGRAM 5 DCHD(6-62) &.LM 7"Z_0 -�1` �pN APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT Davie County Health Department Environmental Health Section R O. Box 665 Mocksville, N.C. 27028 CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.IS Home Phone 7 -F4, 1. Permit Requested B r Business Phone - 9 2. Address jf 7 - mill 3. Property Owner if Different than Above N /14 Address 4. Permit To: a) Install Alter Repair b) Privy Conventional V Other Type Ground Absorption c) Sub-Division Sec. Lot No. 5. System used to serve what type facility: House A Mobile Home Business IndustryOther b) Number of people tl- 6. a) If house or mobile home, state size of home and number of rooms. House Dimensions Bed Rooms—l—Bath Rooms Den w/Closet b) If Business, Industry or Other, State: Number of persons served ' IA What type business, etc. Nle 1lPr7Estimate amount of waste daily (24 hours) '116- 7.1 . Number and type of water-using fixtures: commodes urinals garbage disposal lavatory showers washing machine dishwasher sinks 8. a) Type water supply: Public ✓ Private Community b) Has the water supply system been approved? Yes No 9. a) Property Dimensions �� ACr2. b) Land area designated to building site c) Sewage Disposal Contractor 10. Do you anticipate a y additions or expansions of the facility this sewage system is intended to serve? One- What type? wl 'A- This is to certify that the information is corre t to the best of y kno ledge. tZa - Date Owner Signature OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS `tS Allow 5 days for processing ry Direction% t property: Sewe_ ` `AD qtq !-1 r tf 4 DCHD(6-82)