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P4801 Boxwood Church Rd✓`:.. - __ - ;(a', ev.o ". _�-^^�w.IPu'ai'�`vuwau :vc•vvwa.�.�yy-�iry^,i?.-�4' .vVliba�•� �.v -.. .... __.� _'- -"" _ __v' 'r'. •• _ __ -.. 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 D/isp�osal Rules (10 NCAC 10A .1934-.1968) Permit Number ►game. �Pr Date Location`s'`/<' Subdivision Name Lot No. Sec. or Block No. Lot Size ft' House Mobile Home Business Speculation No. Bedrooms --� No. Baths No. in Family_ -Garbage, Disposal YES ,0 NO ©! Specifications for System: Auto Dish Washer ° rYES 0 NO / , ' f? ✓ , , Auto Wash Machine YE.S-NO Type Water Supply I �:'� _— S�c%C A . v 1 . *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 _0 Certificate of Date Comp letiorf�4�C% 64 *The signing of this certificate shall indicate that the system described above has been installed in :compliance- with'. ` the standards set forth intheabove regulation, but shall. in NO way be taken as.a guarantee that. the.system will function satisfactorily for any given period of time. - APPLICATION FOR SITE EVALUATION/ IMPROVEMENTS PERMIT �l y Davie County Health Department Cp Environmental Health Section ��� P. 0. Box 665 CCC�� Mocksville, N.C. 27028 R` CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED. I Home Phone��o 1. Permit Requested By Business Phone'i 2. Address 3. Property Owner if Different than Above Address 4. Permit To: a) Install Alter Repair b) Privy -P Conventional Other Type Ground Absorption c) Sub -Division Sec. Lot No 5. System used to serve what type facility: House 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 Dimensions JIV ?0 Bed Rooms—_ Bath RoomsDen 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 a showers % washing machine Z dishwasher, sinks L4 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 10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve? AY 0— What type? This is to certify that the information is correct to the best of my knowledge. Date '!z zm� Owner Signatur OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS Allow 5 days for processing Directions to property: �D d rj?t " 47Z DCHD (6-82) Name— Address DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section R O. Box 665 Mocksville, N.C. 27028 SOIL/SITE EVALUATION Date Lot Size FACTORS AREA 1 ARFA 2 AREA 3 ARFA d 1) Topography/ Landscape Position S S S P PS PS PS U U U U ?) Soil Texture (12-36 in.) Sandy, S S S Loamy, Clayey, (note 2:1 Clay) (Esr/ PS PS PS U U U U 1) Soil Structure (12-36 in.) S S S Clayey Soils(* P PS PS PS 'Tj U U U I) Soil Depth (inches) S S S PS. PS PS U U U i) Soil Drainage: Internal S S S PS PS PS PS U U U External . S S S PS PS PS PS U U U 1) Restrictive Horizons Available Space S S S PS PS PS PS U U U 1) Other (Specify) S S S S PS PS PS PS U U U U 1) Site Classification U—UNSUITABLE Recommendations/ Comments: Described by SITE DIAGRAM DCHD (6-82) S—SUITABLE .-PS—Provisionally Suitable Title 4 Date