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3956 Hwy 601NDAVIE COUNTY HEALTH DEPARTMENT r r IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION s`� 6�CaQ`" eD "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 �.isl1'i'.r .% ;ci;�S �f�../� Dated j' j f/L/ ♦ T ^l Zr'^,r-�'" `j�s 7 C. /�/�. /�%/C. i "� C� / Lr / /f ,� Location _ Subdivision Name Lot No Sec. or Block No. Lot Size House Mobile Home _ L-� Business Speculation No. Bedrooms r,. _ No. Baths �? No. in Family Garbage Disposal Auto Dish Washer Auto Wash Machine Type Water Supply YES ❑ NO []- YES YES ❑ NO ❑ YES � NO ❑ Specifications for System: _J Jr C1`i/t/�� `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 Certificate of Completion _ Date ' /%i� g / "I•/ "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. . Address FArT()RS DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. 0. Box 665 Mocksville, N.C. 27028 SOIL/SITE EVALUATION ARFA 1 AREA 2 Date �1—/ Lot Size . Z AREA 3 AREA 4 Topography/ Landscape Position S S PS U S PS U U !) Soil Texture (12-36 in.) Sandy, Loamy, Clayey, Clay) S PS S PS (note 2:1 P U U U 1) Soil Structure (12-36 in.) Clayey Soils PS S ( S PS S PS �j U U �) Soil Depth (inches)dr5 S PS S PS U U U i) Soil Drainage: Internal S PS S PS S U U U External S PS U S PS U �) Restrictive Horizons Available Space © PS S PS S PS U U U U 1) Other (Specify) S PS S PS S PS S PS U U U. U 1) Site Classification l U—UNSUITABLE Recommendations/Comments: Described by _ SITE DIAGRAM DCHD (6-82) S—SUITABLE PS—Provisionally Suitable Title Datei�� 1. Permit F 2. Address Sly 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. i - quei Bpi �/6i Business Phone Home Phone 3. Property Owner if Different than Above Address 4. Permit To: a) Install C-'�'Alter Repair b) Privy Conventional her Type Ground Absorption c) Sub -Division Sec.— Lot No. 5. System used to serve what type facility: House Mobile Home usiness 0 Industry Other b) Number of people 6. a) If house or mobile home, state size of home and number of rooms. House Dimensions 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 of water -using fixtures: commodes lavatory urinals showers 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 garbage disposal washing machine 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. L ' Date Own Signature OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS Allow 5 days for processing Directions to property: DCHD (6-62)