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173 Leanne Ln( ` `_ .. - d� c>cx..w::: '!i aa;<.:�-`i., eye.,.., ::a.. i di'.: -•.'"i, w>a.`,a-"-'.t..-ro:1i:. a�:.,.n„---. - - 'A /U� :. DAVIE COUNTY HEALTH 'DEPARTMENT. I; 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 INCAC 10A .1934-.1968) Perinit =Number . f! Name /; ' �>'r'.%,� 1�%' f, i� `� .�1s%:.f4ate NR .4548 Location ri`?/ "'�' .' ..�✓ �. E �r' i ✓ �.s r'� Subdivision Name Lot No. Sec. or Block No. Lot Size /�� House Mobile Horne _ Business Speculation ii No.'Bedrooms—, - No.. Baths; No., in' Family . Garbage Disposal YES ❑. NO Specifications for System'. g =Auto Dish Washer; YES NO ❑� r. r`r� ; , "Auto Wash Machine YES g NO 0 Type Water Supply I' *This permit Void if sewage system described below is not installed within.36 months fro dat .of issue. i - u , . Improvementsy ermit b i .. P I *Contact a representative of the Davie County Health Department for final ' inspection of this system -between 8:30- 9:30 30-9:30 A.M. or 1:00-1:30 P.M. on day. of completion. Telephone Number: 704-634-5985. !i• .Final Installation Diagram: w•-���. �•� � - � •"System Installed by ;Certificate of Completion_ Date '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 F satisfactorily for any given period of time.. t DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section R O. Box 665 Mocksville, N.C. 27028 SOIL/SITE EVALUATION Name Date Address Lot Size E FACTORS AREA 1 AREA 2 AREA 3 ARFA d 1) Topography/ Landscape Position S S S S PS PS PS U 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 3) Soil Structure (12-36 in.) S S S Clayey Soils (k) PS PS PS U U U U I) Soil Depth (inches) S S S S PS PS PS U U U U i) Soil Drainage: Internal S S S PS PS PS U U U U External S S S PS PS PS U U U i) Restrictive Horizons !� Available Space PS S S S PS PS PS U U U U i) 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 5�y Date llyhllse APPLICATION FOR SITE EVALUATION/ IMPROVEMENTS PERMIT Davie County Health Department Environmental Health Section R 0. Box 665 Mocksville, N.C. 27028 CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED. 'Home Phone (PPermit Requested By ©Al Business Phone (J�Address 71 c36 X a5 - /4 3. Property Owner if Different than Above Address 4. Permit To: a) Install�Alter Repair b) Privy - Conventional,�_L6ther Type Ground Absorption c) Sub -Division Sec. Lot No. 5. System used to serve what type facility: House Mobile Home Business IndustryOther umber of people 3 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 9. a) Property Dimensions— b) imensions garbage disposal washing machine 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. /� - 8 G � a am Date Ow er Signature OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS Allow 5 days for processing Directions to property: DCHD (6-82)