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2117 Hwy 64W ' DAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION *NOTE: Issued in Compliance with G.S. of North Carolina Chapter 130 Article 13c t/ Sewage Treatment and Disposal Rules (10 NCAC 10A .1934-.1968) Permit Number Name tAJ1L1"IAAL Date �© a `�/ '� 3713 Location Subdivision Name Lot No. Sec. or.Block No. Lot Size House '� Mobile Home _ Business Speculation No. Bedrooms No. Baths d No. in Family Z_ Garbage Disposal YES p NO p Specifications for System:Joao Auto Dish Washer YES NO Auto Wash Machine YES NO ❑ l-5 f "-�3N` Type Water Supply 401,tj --- '� - ��'` o-,— Ca,---c ,e r.- ,t= *This permit Void if sewage system described below is not installed within 36 months from date of issue. � FtzoNT- Improvements permit b p *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 Completion '� Date Id ro *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. AV DAVIE COUNTY, HEALTH DEPARTMENT i 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 W iLLIAfl'- � Date�a ! �� r ? `% 13 Location&`/ s — Subdivision Name Lot No. Sec. or Block No. Lot Size House Mobile Home _ Business Speculation No. Bedrooms _ No. Baths �'� No. in Family Z—_ Garbage Disposal YES .E] NO p Specifications for System:/600J4 Auto Dish Washer YES NO p ' '' - Auto Wash Machine YESE NO ,0 ���� `� f l�s�✓r 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. Final Installation Diagram: System Installed by AIN JiN 1�2 Certificate of Completion ��—v 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. Y DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section R O. Box 665 Mocksville, N.C. 27028 +A' ! SOIL/SITE EVALUATION p Name Date Q r Address � Lot Size Z70 z-Q' FACTORS AREA 1 AREA 2 AREA 3 AREA 4 1) Topography/Landscape Position S SS PS U 1P U U 2) Soil Texture (12-36 in.) Sandy, S S S S Loamy, Clayey, (note 2:1 Clay) ® , PS U U U U 3) Soil Structure (12-36 in.) S S S S Clayey Soils 4S) (M (M PS U U U U 4) Soil Depth (inches) S S (P'S� PS U U U 5) Soil Drainage: Internal 6 (ZD PS External � S 4 S ® PS U U U U 6) Restrictive Horizons 7) Available Space ® 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 U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable Recommendations/Comments: Described by Title "s' Date SITE DIAGRAM DCHD(6-82) r y° 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. �Q�y�93 Home Phone 1. Permit Req ted B �• Business Phone 2. Address 3. Property Ow ifferent than Above Address n ) Df fvr 4. Permit To: a) Install er Repair b) Privy Conventional Other Type Ground Absorption c) Sub-Division Sec. Lot No. 5. System used to serve what type facility: House 1-19t6bie Home Business IndustryOther b) Number of people / 6. a) If house or mobile home, state size of home and number of rooms. House Dimensions x �a 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 off want 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 b) Land area designated to building site c) Sewage Disposal Contractor 10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve? What type? This is to certify that the information is correct to the best of my k owledge. Date Owner Signatur OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AN LOCAL LAWS Allow 5 days for processing Directions to property: l R 6 G Ize i%F_.,r-r FAS 7- A?6S111 s � w DCHD(6-82) i • DAVIE COUNTY HEALTH DEPARTMENT SITE EVALUATION 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 14UST BE DONE BEFORE A SANITARIAN WILL BE ABLE TO BEGIN THE REQUESTED EVALUATION. DETACH HERE AND RETURN TO TIiE(DAVIE COUNTY HEALTH DEPARTMENT,P.O. BOX 57) (I4OCKSVILLE, N.C. 27028) DAVIE COUNTY HEALTH DEPARTMENT SITE EVALUATION CONSENT FORM `LOCATION OF PROPERTY: DATE RECEIVED t14 LI) 14 (� (� GS- -- (office use only) 11D -13 rnoG�� ✓,L� c ISG �-�� - � yes no (1.) I am the owner of the above described property. yes no .) I am not the owner of the ab dPscribed pr( er y, � >;,/I certify that I have consent fisc, eyr! L� ( /yf e¢- '' 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.) I hereby give consent to the authorized representative of the II Davie County Health Department to enter upon the above described. 1__1 property and conduct all testing procedures necessary to determine its suitability for a ground absorption sewage disposal system. �7�3 ATE SIGNATURE Vk (4.) I hereby authorize the Davie County Health Department to release site evaluation results from the above described property to the following: er Only g/g,/- 3 -g��Ownerls designated representative ( Anyone requesting results DATE only Only those listed be w SIGNATURE