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307 Oakland Avenue Lot 122 & 123k 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 TO II C)w€Ns Date! y - 'A 3712 Location if Subdivision NameMf'7 + la Lot . Sec. or Block No, Lot Size II House ' Mobile Home — �4 Business Speculation I' No. Bedrooms —a --L No: Baths •-2— No. in Family Garbage Disposal YES p NO ©'Specifications for. System: moo tiw l t Auto Dish Washer ' YES NO Auto Wash Machine YES W NO F-1 zc�G x -S X l S S 1-0 I Type Water Supply --- _ ` '�" �,— 'a �- (e f. 9 C �I *This permit Void if sewage system described below is notJnstalled within 36 months from date of issue. .I - • it 'I - . Improvements permit y 'Contact a representative ofd the Davie County Health Department for final inspectionof this system between 8:30- 9:30 A.M..or 1:00-1:30 P.Kv. on day of completion. Telephone Number: 704-634-5985. Final Installation Diagram: System Installed by L± -ice SA",r-i'L".- Certificate of Completion Date "The signing of this certificate shall indicate that the system described, above has been instajled 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. O. Box 665 Mocksville, N.C. 27028 SOIL/SITE EVALUATION Name N tJ }{ , O W £MS Date w" 3^ S T Address Q'f• ('o Lot Size Atoc.Ins if#L 1JG. 27oZ9' FArrnac APPA 1 AREA 2 AREA 3 AREA 4 w Topography/ Landscape Position S S S S PS PS PS U U U U !) Soil Texture (12-36 in.) Sandy, S S S S Loamy, Clayey, (note 2:1 Clay) (E'!�) PS PS PS U U U U 1) Soil Structure (12-36 in.) S S S S Clayey Soils PS PS PS PS V U U U Soil Depth (inches) Q S S S PS PS PS PS U U U U �) Soil Drainage: Internal S S S PS PS PS U U U U ExternalS S S S PS PS PS U U U U i) Restrictive Horizons ') Available Space PS S- PS S PS S PS U U U U !) Other (Specify) S PS S PS S PS S PS U U U U Classification T S PS 1) Site U—UNSUITABLE Recommendations/Comments: J&W5 S—SUITABLE If PS—Provisionally Suitable Described by Sfw Title SA-'4TAM, A-1 SITE DIAGRAM DCHD (6-82) \- Date -'&-9'V 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. 1. Permit Requested By 2. Address K+ (a 3. Property Owner if Different than Above Address 4. Permit To: a) Install Alter Repair b) Privy Conventional Other Type Ground Absorption HomePhone 1V 9 a — �� 3 Business Phone 63 y c) Sub -Division Sec. Lot No. 5. System used to serve what type facility: House Mobile Home Business IndustryOther b) Number of people 6. a) If house or mobile home, state size of home and number of rooms. House Dimensions Va )( 4_ - Bed Rooms_ Bath Rooms l Ya Den w/Close 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 V urinals lavatory showers dishwasher sinks 8. a) Type water supply: Public Private Com ity b) Has the water supply system been approved? Yes o 9. a) Property Dimensions garbage disposal washing machine ve` 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 FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS Allow 5 days for processing Directions to property: Cie �,r ( 64 Vag+ a)t_e- �n�L t~t'S On ��� of\ 9 ` CNA `Jho . r) i- mac sS S-� o V- f (-' 0_X M '-� V3ca-e-i; o\ p 0_0 (e, clb V__y � � 111 10i 1 as C�k- \a3 DCHD (6-82) DAVIE COUNTY HEALTH DEPARTMENT SITE EVALUATION CONSE14T 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 MUST BE DONE BEFORE A SANITARIAN WILL BE ABLE TO BEGIN THE REQUESTED EVALUATION. DETACH HERE AND RETURN TO THE(DAVIE COUTITY HEALTH DEPARTMENT,P.O. BOX 57) (MOCKSVILLE, N.C. 27028) DAVIE COUNTY HEALTH DEPARTMENT SITE EVALUATION CONSENT FORM LOCATION OF PROPERTY: DATE RECEIVED (office use dnly) yes no-, (1.) I am the owner of the above described property. yes no (2.) I am not the owner of the above de r' ed rty, however, I certify that I have consent from ,, .,owner to wner'ro 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 Davie County Health Department to enter upon the above described property and conduct all testing procedures necessary to determine its suitability for a ground absorption sewage disposal system. ---, - �' �y DAtE SI TURF (4.) I hereby authorize the Davie County Health Department to release site evaluation results from the above described property to the following: • it ai r .,JE is A /1 SqNATURE Owner Only Owner's designated representative [� Anyone requesting results Only those listed below I 0 � N bQ� I � Cn 1 N. cs i t 0 � N bQ� � Cn 1 N. i t 0 bQ� � Cn 1 � g Aj 81 ,I Si0'8a� C�. � r � ,I C�. 07 t / i I