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P3179 Main Church Rd--' ` DAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION ; *Note: Issued in Compliance with G.S. of North Carolina Chapter 130—Article 13c. Permit Number Name �j, c f tw t (,; ��z tJ Date r r Location %•} Jl 'nIfl'PJ c> %'U 0 s_ - Subdivision Name Lot No. Sec. or Block No. Lot Size House Mobile Home _ ✓ Business Speculation No. Bedrooms No. Baths __ No. in Family 3'__ Garbage Disposal YES ❑ NO ❑" Specifications for System: /00C Auto Dish Washer YES ❑ NO ❑ 'IX L Auto Wash Machine YES E:] NO ❑ 3 X l:� SToytJ Type Water Supply _— *This permit Void if sewage system described below is not installed within 36 months from date of issue. Improvements permit by e.J *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 AOL Certificate of Completion Date �` �' — �— *The signing of this certificate shall indicate that the system descr b/ed 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 P. O. Box 665 Mocksville, N.C. 27028 SOIL/SITE EVALUATION Name � ASKf3cJ/ZN Date I — ��'` 83 Address 3 & Ao Lot Size /K,ocasVlcL£ AIC "C-Zy cerrrnoc APPA 1 AREA 9 ARFA R ARFA d 1) Topography/ Landscape Position Q (J S S PS PS PS PS U U U U '.) Soil Texture (12-36 in.) Sandy, Loamy, Clayey, (note 2:1 Clay) S Q S q S PS U S PS U 1) Soil Structure (12-36 in.) S S b S PS S PS Clayey Soils ® U .0 U U 1) Soil Depth (inches) 0 PS 0 PS S PS S PS / / U U U U i) Soil Drainage: Internal © a S S PS PS PS PS U U U U External 0S S PS S PS PS U U U U i) Restrictive Horizons ') Available SpaceS S PS 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 U—UNSUITABLE S—SUITABLE / PS—Provisionally Suitable Recommendations/ Comments: Described by£LiS -- Title SITE DIAGRAM fr'1-Cz DCHD (6-82) Date 1-14_ a r—J41C E /'%0 DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section R O. Box 665 Mocksville, N.C. 27028 SOIL/SITE EVALUATION Name— Date Address '�T S Lot Size �' Z Acres isL 2 7 o2Sl �er.Tnctc AREA 1 AREA 9 AREA 3 AREA 4 1) Topography/ Landscape Position 2) #) 5) �) 8) 9) t S d ® S PS PS PS PS U U U U Soil Texture (12-36 i S S S S Loamy, Clayey, (not 2:1 Clay) PS ® S PS C) PS U 1) Soil Structure (12-36 in.) Clayey Soils S � ira� Jc- S & S � S US Soil Depth (inches) S S S S PS 0) PS 0 PS M PS U Soil Drainage: Internal S S S S PS PS PS PS S U External S PS S PS S PS S PS U U U U Restrictive Horizons Available Space S PS S. PS S PS S PS U U U U Other (Specify) S PS S PS S PS S PS U U U U Site Classification U—UNSUITABLE S—SUITABLE Recommendations/ Comme . Described by SITE DIAGRAM DCHD (6-82) PS—Provisionally Suitable Title S7-kN , n-'`a'L� Date l - '0 - F3 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- 1' F.3 2 1. Permit Requested By y Yl Business Phone 2. Address of � -3 i3ax I/o j�i��kY�,�`«�_ t 2'?Ogg 3. Property Owner if Different than Above Address 4. Permit To: a) Installer 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 ✓ Business IndustryOther b) Number 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 ✓ urinals garbage disposal lavatory showers washing machine dishwasher sinks 8. a) Type water supply: Public Private_I Community b) Has the water supply system been approved? Yes No 9. a) Property Dimensions 1, ) 2 acnes 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? ►'1 What type? This is to certify that the information is correct to the best of my knowledge. Date Owner Signature OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS Allow 5 days for processing Directions to property: Lj Jt.0. b(oc by 1 i Z q /c�� or DCHD (6-82)