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190 Legion Cemetery St ,r'' . G,J.'Q, r-..•�, w .. ..... .J t 1 DAVIE COUNTY HEALTH DEPARTMENT N -� IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION *NOTE: Issued in Compliance with G.S. of North Carolina Chapter 130 Article 13c Sewage Treatment as d`Disposal Rules (10.NCAC 10A .1934-.1968) j Permit Number Name 0 ;tl,`0.17, l Date I �r �''1s 3572 Location Subdivision Name Lot No. Sec. or Block No. Lot Size ZY House � Mobile Home _ Business Speculation No. Bedrooms No. Baths t� No. in Family Garbage Disposal YES ❑ NO ❑ Specifications for System: Auto Dish Washer YES Ej NO > �.-�,- �•��' �l f) '" 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. tv " Improvements permit by *Contact a representative of the Davie County Health Department for final inspection of this system between 8:302 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_ o�4 .6-�L c r7 G, I�J Certificate of Completion 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. - ' 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 Date .��1'_ ; �;_A° 3572 Location x"��rf /i' , i , /�'- ✓ /�^/l r rF r' . r Subdivision Name Lot No. Sec. or Block No. Lot Size %-'' House "-Mobile Home _ Business Speculation No. Bedrooms 1 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. f SO -- 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 Q�- ----------------- Certificate of Completion M ag o 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. DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section R O. Box 665 Mocksville, N.C. 27028 SOIL/SITE EVALUATION Name6&4'�Zffa Date Z/ Address Lot Size li;lz;7 . FACTORS AREA 1 AREA 2 AREA 3 AREA 4 1) Topography/Landscape Position S S S S © © 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 PS U U 3) Soil Structure (12-36 in.) S / S S S Clayey Soils © PS PS PS U U 4) Soil Depth (inches) S S S S p PS PS U U U 5) Soil Drainage: Internal S S S S PS PS PS PS U U External S S S ® 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 U—UNSUITABLE /S—SUITABLE PS—Provisionally Suitable Recommendations/Comments: JL - Described by Title Date SITE DIAGRAM ell Ile 0 wX404 DCHD(6-82) APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT 1 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. Home Phoneme y- '7�0 1. Permit Re"�tedB Busi ess Phi 2. Address �:e� e . G 3. Property Owner if Different than Above %� - Address 4. Permit To: a) Install Alter Repair (� 0) Privy Conventional Other Typea�" Ground Absorption �( c) Sub-Division Sec.— Lot Na 5. System used to serve what type facility: House Mobile Home Business— Industry— usiness IndustryOther b) Number of people 6. a) If house or mobile home, state size of home and number of rooms. House Dimensions Bed RoomsBath 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 j urinals garbage disposal lavatory showers washing machine j dishwasher sinks 3� 8. a) Type water supply: Public Private e�Community b) Has the water supply system been approved?Yes No 9. a) Property Dimensions— b) imensions 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? 2� What type? ' This is to certify that the information is correct to the best of my knowledge. Q 1, Gi / Date Owner Signature OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS Allow 5 days for processing Directions to property: /? A41- Ac4e-o-r F� l oo DCHD(6-82) On this day of AAL 1984, I, Nancy Shore Durham, of Davie County, owner of property located in Jerusalem Township, Davie County, State of North Carolinas Deed Book III, page 335 in Davie County Courthouse and Thomas Ray Shore, owner of adjacent lot, having water rights from a well located on property of Nancy Shore; Durham do this day sign an agreement giving the Enviromental Health Section of Davie County Health Department. {he right to approve a septic tank less than 100 feet and not less than 50 feet from this well. Should any contamination arise from this, the Enviromental Health Section of Davie County Health Department is clear of any charges. Signed ZZ: i Signed w e This agreement is witnessed and certified by mt.�n ����t --• j i r,