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P4829 Gladstone 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 Sewage Treatment and Disposal Rules (10 NCAC.10A .1934-.1//968)' Permit Number Name c Date � g Location 4 ,!%'.i,.`-�"' 1/` ,• :,�'r--rrrst o,�•''�, ,�.�.�/ls'��7�! ,fir" �I Subdivision Name. Lot No. Sec. or Block No. Lot Size , House Mobile Home _ � Business Speculation No. Bedrooms— N0. Baths.— _ No. in Family ' Garbage Disposal. YES ,E] 'NO [2' i Auto Dish'Washer YES NO Specifications for System: +' ' . . p.. Auto Wash Machine YES [ ] NO ff Type Water Supply _- _tom rYJ'a' �1 ii *This•permit Void if sewage system described•below is not installed within 36 months from date of issue: it • Improvements permit,.kiy _ 6 ; *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. ion day'of•:completion. Telephone umber: 704-634-5985. ! • ., it Final Installation Diagram: S stem I talled by 70 /5 •��1r�C !, Certificate of Completion �' Date 'I �• , 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. c � t 0 APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT Davie County Health Department Environmental Health Section P O. Box 665 RECEIVED MAY 2 9 11487 �C;'?�2 Mocksville, N.C. 27028 J CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED. Home Phone 1. Permit Requested B � c Business Phone 2. Address rs i l 3. Property Owner if Different than Above c- f 5' 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 V Business Industry Other b) Number of people 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 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? What type? This is to certify that the information is correct to the best of my knowledge. 1 8, --"11 qpd*z"Date U Owner Signature OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS Allow 5 days for processing Directions to property: G o . r n r i 5 h� o n CLct +o n� p cL / h;e n go. +o Li-IYOR Pc o u�)1 j- - 0 &A, O n rl L n e_ � b o k 0 tL.5 e— G" m c� G4 o nc. DCHD(6-82) „ i DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. 0. Box 665 Mocksville, N.C. 27028 SOIL/SITE EVALUATION / Name /�C1�� � t Date 6 Address Lot Size 1pwe FACTORS A EA 1 AREA 2 AREA 3 AREA 4 1) Topography/Landscape Position S S PS PS PS U U 2) Soil Texture (12-36 in.) Sandy, S S Loamy, Clayey, (note 2:1 Clay) S PS PS PS U U 3) Soil Structure (12-36 in.) S S Clayey Soils S PS PS PS U U 4) Soil Depth (inches) S S PS PS PS U U 5) Soil Drainage: Internal S S Ig PS PS PS U U External S S S PS PS U U 6) Restrictive Horizons 7) Available Spaceis S S PS PS U U U 8) Other (Specify) S S S S PS PS PS U U U 9) Site Classification t i U—UNSUITABLE S—SUIT LE /–PS—Provisionally Suitable Recommendations/Comments: Described by Title Date SITE DIAGRAM eelD f YI I �4 DCHD(6-82)