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138 Gladstone Rd„ ,. ,,..-.. .:.e.-.a•w.e.1.v... a.r ....,y.e:,.�.ry.-,.. n,-.++..-. .... .,, •P_• .... �.. ... - . .. .... -. .. ... .. - ..... .. .. ,, i DAVIE COUNTY HEALTH DEPARTMENT 1 j� 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 NCAC 10A .1934-.1968)” / Permit Number Name !/r; ;%.,i, r o.':.� .) Date ZZ✓Z NJ o 4173 Location' Subdivision Name Lot No. Sec. or Block No. Lot Size House Mobile Home Business __ Speculation No. Bedrooms J No. Baths J No. in Family_' _ Garbage Disposal YES ❑ NO ❑ Specifications for System; Auto Dish Washer YES ❑ NO ❑ Auto Wash Machine YES, ❑ NO ❑ r f Type Water Supply *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: DI System Installed by ,�% ►, z n n ;a �� .,T � w TMJ --/deo - ✓� IMH Kj 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 satisfactorily for any given period of time. APPLICATION FOR SITE EVALUATION/ IMPROVEMENTS PERMIT Davie County Health Department Environmental Health Section R O. Box 665 Mocksville, N.C. 27028 CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED. Home Phone��� 1. Permit R st By��'✓i ©� Business Phone 2. Address '► 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 Mobile Home &--tusiness IndustryOther b) Number of people �! 6. a) If house or mobile home, state size of home and number of rooms. House Dimensions Bed Rooms %_T 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? Yeses No 9. a) Property Dimensions 4L Xl?doZ� 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. 4f4c'e, Date 61 Owner Signature OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS Allow 5 days for processing Directions to property: DCHD (6-82) Name— Address DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Box 665 Mocksville, N.C. 27028 SOIL/SITE EVALUATION Date Lot Size FACTORS AREA 1 AREA 2 AREA 3 ARFA d 5 8) 9) Site Classification 1) Topography/ Landscape Position S S S PS � PS PS U U t) Soil Texture (12-36 in.) Sandy, S S Loamy, Clayey, (note 2:1 Clay) PS PS PS PS U U !) Soil Structure (12-36 in.) S S Clayey Soils PS PS PS PS U U U l) Soil Depth (inches) S S S S PS > PS PS U U ) Soil Drainage: Internal S S pS PS PS U U U External S S p PS PS PS U U Restrictive Horizons Available Space S S S' PS PS U U U Other (Specify) S S S S PS PS PS PS U U U U U—UNSUITABLE Recommendations/ Comments: S—SUITABLE PS—Provisionally Suitable Described by Title -�z] Date SITE DIAGRAM DCHD (6-82) U—UNSUITABLE Recommendations/ Comments: S—SUITABLE PS—Provisionally Suitable Described by Title -�z] Date SITE DIAGRAM DCHD (6-82)