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206 Murphy 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 4�11e %� /� Date l= %. r ti s� 3557 r n i Location i� 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 ❑ ,�;, � .�, <, �j u 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 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 i 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 betaken as a guarantee that the system will function . satisfactorily for any given period of time. .JL DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. 0. Box 665 Mocksville, N.C. 27028 SOIL/SITE EVALUATION Name Date Address 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) /9 PS PS U U U U 3) Soil Structure (12-36 in.) SS S Clayey Soils PS PS U U U U 4) Soil Depth (inches) SS S S PS PS U U U U 5) Soil Drainage: Internal S _ S S PS PS U U U External S S S S —._ PS PS U U U U 6) Restrictive Horizons 7) Available Space SSS. 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 U—UNSUITABLE S—SUITABLE PS— rovisionally Suitable Recommendations/Comments: Described by Title S''� Date SITE DIAGRAM X J �2v�T DCHD(6-82) 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 UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED. Home Phone 119Z'57g3 1. Permit Requested By L Business Phone 2G-(D00 2. Address IMA r-Lls v;Ile- 3. le3. Property Owner if Different than Above ►'Y)Ae it Pja Address P-1" & • Box 306 /Y) orlfs4.;/Ie Al 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,HomeJe::::Business IndustryOther b) Number of people 3 6. a) If house or mobile home, state size of home and number of rooms. House Dimensions-2 q q Bed Rooms 3 , 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 Z urinals garbage disposal lavatory 2- showers washing machine dishwasher 1 sinks I 8. a) Type water supply: Public—Private Communityc gUwTr wAT-eY b) Has the water supply system been approved? Yes No 9. a) Property Dimensions 7 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 knowledge. Date : Owner Signature OWNER IS SOLELY RESPONSIBLE rOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS :"Allow 5 days for processing Directions to property: g9e,.ir-, t -- DCHD(6-82) .