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264 Bailey RdDAVIE COUNTY HEALTH DEPARTMENT'' IMPROVEMENTS O MENTS PERMIT AND CERTIFICATE OF. COMPLETION, . ;NOTE: Issued in Compliance With'.G.S. of North �iCa'rolirra Chapter 130 Article '13c Sewage Treatment and Disposal Rules (10 NCAC. 10A .1934-.1968)1,.Permit Number Name/�{ =r r�� ;. I� i! Date 11 36-'9 Location �p j r-AdSubdivision Name Il l' ' Lot No. II Sec..or Block No. Lot Size .% H - se Mobile Home �---� Business Speculation No. Bedrooms III- NQ �� li �_ No. Baths �! � No. in Family Garbage Disposal YES Nb.;fn' Auto I� Specifications for S stem: Dish Washer YES NO'0 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.. I i Ili 7 `^F G•v l-' �{I .. v I; i� 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. ill . G , Final Installation Diagram: ii System Installed 6,y' I I' Certificate of Completion YV QM Date 'The signing of this certificate shall 'indicate thatljthe system described above has been installed: in compliance with the standards set forth'in the above'regulation,'bbt shall in NO-Way betaken as a guarantee that the\system will function t satisfactorily for any given period of:time. I il. Address DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section R O. Box 665 Mocksville, N.C. 27028 SOIL/SITE EVALUATION Date, , Lot Size�� FAr..TnRc ARFA 1 AREA 2 AREA 3 AREA 4 Topography/ Landscape Position S S S PS PS PS U U U !) Soil Texture (12-36 in.) Sandy, S S S Loamy, Clayey, (note 2:1 Clay) PS PS PS U U U U 1) Soil Structure (12-36 in.) S S S Clayey SoilsPS PS PS PS U U U Soil Depth (inches) S S S p PS PS PS U U U ) Soil Drainage: Internal S S S S PS PS PS U U U External S S S PS PS PS PS U U U 1) Restrictive Horizons Available Space PS S 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 I i U—UNSUITABLE Recommendations/ Comments: Described by SITE DIAGRAM DCHD (6.82) S—SUITABLE __ PS—Provisionally Suitable Title�� 0 APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT � 2 Davie County Health Department JC ' Environmental Health Section \� R O. Box 665 i Mocksville, N.C. 27028 CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED. Home Phone MKI) g0+002O 1. Permit Requested By B l hent ".E1,155F LL , Business Phone N lq) -705- 4Q0 I 2. Address 561"1 A'i A2U:A:' , w -5. 0 G 0-7 10 (-P 3. Property Owner if Different than Above Z Elio T : HnoT5 Z+ 0_1 Address WImin-,Y� -SmLlYl IKG 4. Permit To: a) Install Alter Repair b) Privy Conventional Other Type Ground Absorption c) Sub -Division r�►"-4y\ Sec. Lot No 5. System used to serve what type facility: House Mobile Home Business IndustryOther b) Number of people 3 6. a) If house or mo ' e h me, state size of home and number of rooms. House Dimensions Ill x -7& 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 lavatory showers washing machine dishwasher I sinks 3 8. a) Type water supply: Public Private— Community C W) b) Has the water supply system been approved? Yes No 9. a) Property Dimensions / 000 P+ X 0460 -P b) Land area designated to building site 40 auuo c) Sewage Disposal Contractor 10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve? NO What type? This is to certify'that the information is correct to the best of my knowledge. Date ner Signature OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS Allow 5 days for processing a.,. Directions to property: 15 8 $ p 9 acklo orlt ` 3e oq_A "� �dlvr�Ce , %tos 5 � Imo' � � �--j �J let . C`I d ap.PAOV I ryWJJ2-9 r 4 m i 1 e 1 1 —t -U &SI aA_e--_Pd I U 5 -1) I JKZO i/D a, 9 Yar�e e.. rd. �J JmLto 06 hWZQZ,::�? � ► h o -ad Lnd ecL-40 C-enqcr tb �opo�l ole �' 5 up rno" -f- cy""c DCHD (6-82) Vv[ �/ 1 V 7'I 1 ,n I,. DAVIE COUNTY HEALTH DEPARTMENT SITE EVALUATION CONSENT FORM LOCATION OF PROPERTY: DATE RECEIVED (office use only) yes -no (l.) I am the owner of the above described property. yes no (2.) I am not the owner of the above described property, however, I ox C] certify that I have consent from f3;pll _ 07S _,owner to ow is 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. !�?_Z4=D-- V DATE W, W �"y Mejklfty kill, Ma (4.) I hereby authorize the Davie County Health Department to release site evaluation results from the above described property to the following: `7/.h ��- DATE SIGNA 0 Owner Only XJ Owner's designated representative ( Anyone requesting results �1 Only those listed below