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1686 Angell Rd' -T. 41i DAVIE COUNTY HEALTH DEPARTMENT _ IMPROVEMENTS PERMIT ANI) CERTIFICATE OF COMPLETION *NOTE: Issued inCompliance with G.S.nf North Carolina Chapter 130 ArUo|o 13o Sewage Treatment and Oiopnea| Rules (10 NCAC 10A .1934-.1968) Permit Number Nome Location Subdivision Name Lot No. Soo. or Block No. Lot Size House Mobile Home _-__-_-_Business __-_-_-_ Speculation ------_-_ No. Bedrooms No. Baths No. in Family Garbage Disposal YES E] NO'0Specifications for System: - Auto Dish Washer YESNO E)! Auto VVoohK4aohine YES �� NO [� ' Type Water Supply *This permit Void if sewage system described below is not installed within 36 months from date of issue. ments permit by *Contact o representative of the Dove County Health -1:30 P.M. on day of completion. Telephone Numbe :704-634-5985. Final Installation Diagram: |edby Certificate of Completion Date 'The signing of1hio/oer ifioabe shall indicate that the described b has been installed in compliance with the standards set forth |n -the above regulation, but shall inNOway betaken aoaguarantee that the system will function satisfactorily for any given period of time. ,. APPLICATION FOR SITE EVALUATION/ IMPROVEMENTS PERMIT 1 Davie County Health Department Environmental Health Section RECEIVED ay .+ P. 0. Box 665 �3 30 Mocksville, N.C. 27028 CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMITS BEEN ISSUED. --� _ - Home P� ne � q 1. Permit Re sted Byu 1 M 4 S� I � 1 m P50 tJ Business Phone r_1 (08 ` 4:Q Sb 2. Address i 1, x 1 -� t �y�1'1CF , N a� © O 3. Property Owner if Different than Above Address 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 -le— Mobile Home Business Industry Other b) Number of people 6. a) If house or mobile home, state size of home and number of rooms. House Dimens. 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 urinals © garbage disposal O 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 3 �)'DI x &0 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 kno ledge. Date Owner Signatu OWNER IS SOLELY RESPONSIBLE FOR COMPLIAN E WITH ALL STATE AND LOCAL LAWS Allow 5 days for pr cessing Directions to property: co o 3K�iw �U l tJha �_=7_ L DCHD (6-82) Name_ Address E DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Box 665 Mocksville, N.C. 27028 SOIL/SITE EVALUATION Date Lot Size FACTORS ARFA 1 ARFA 9 ARFA 3 ARFA d 1) Topography/ Landscape Position C U S PS U S PS U ?) Soil Texture (12-36 in.) Sandy, Loamy, Clayey, (note 2:1 Clay) l pS' �-U S PS S PS U U 3) Soil Structure (12-36 in.) Clayey Soils S PS S PS U U U U " 1) Soil Depth (inches) S S PS S PS U Tj U U i) Soil Drainage: Internal ( U S PS U S PS U External U S S PS U S PS U i) Restrictive Horizons -- Available Spaceis PS U U S PS U S PS U 1) Other (Specify) S PS U S PS U S PS U S PS U 1) Site Classification U—UNSUITABLE Recommendations/Comments: S—SUITABLE PS—Provisionally Suitable Described by �f// Title SITE DIAGRAM /r - DCHD (6-82) Date