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P3241 Hwy 901W} 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 Disposal Rules (10 NCAC 10A .1934-.1968) Permit Number Name])brit"5� tf""I1I nti Date ��3 3241 �` Location �, (�.� _ i CJ �f'�) l %h it/�' t � � ; cr-r r- C0 iC- Subdivision Name Lot No. Sec. or Block No. Lot Size House Mobile Home _ Business Speculation No. Bedrooms -> No. BathsNo. in Family — Garbage Disposal YES ❑ NO Specifications for S stem: x P Y f c)cUO .:. Auto Dish Washer YES NO ❑ Auto Wash Machine YES g NO ❑ Type Water Supply *This permit Void if sewage system described below -is not installed within 36 months from date of issue. k r Sy' 1�7;>•- - 1-1A i caw K 12 0"(- A> r'<SS%i0'c c 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 A22 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. DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section R O. Box 665 Mocksville, N.C. 27028 SOIL/SITE EVALUATION Name Date Address Lot Size CAPTriDQ AREA i AREA 9 AREA 3 AREA 4 Topography/ Landscape Position S S S PS PS PS PS U U U U !) Soil Texture (12-36 in.) Sandy, S 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 Soils PS PS PS U U U U Soil Depth (inches) SS S S PS PS PS U U U U ) Soil Drainage: Internal S S S S PS PS PS U U U U External S S S PS PS PS PS U U U U i) Restrictive Horizons ') Available Space . SS S PS S PS S PS PS y U U U U 1) Other (Specify) S PS S PS S PS S PS U U U U 1) Site Classification U—UNSUITABLE Recommendations/ Comments: S—SUITABLE PS—Provisionally Suitabl Described by Title Date SITE DIAGRAM DCHD (6-82) 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 47 2 ' 5_73Z 1. Permit Requested By a h P, ya4 ba Business Phone C, J 4- R LIZ 2. Address ,rho A 0 /. j2dx 33()a Gtrmen✓ /jC 3. Property Owner if Different than Above Address 4. Permit To: a) InstallZ Alter Rep b) Privy Conventional air Otlier Type Ground Absorption c) Sub -Division Sec. Lot No. 5. System used to serve what type facility: House Mobile Home Business IndustryOther b) Number of peopl 6. a) If house or mobile home, state size of home and number of rooms. House Dimensions SOX 2 $ Bed Rooms---"�' Bath Rooms Z- 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 2 urinals lavatory 2- showers dishwasher , sinks 8. a) Type water supply: Public Private %f� Community b) Has the water supply system been approved? Yes No 9. a) Property Dimensions /• 60 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? "� garbage disposal NO washing machine What type? This is to certify that the information is correct to the bes t of my knowledge. 3 _ 2 '9'3.3 -c '«/it<ZQt,'. • Date 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),