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455 Duard Reavis Rd (2) fo DAVIE COUNTY HEALTH DEPARTMENT5. IMPROVEMENTS PERMIT:AND CERTIFICATE OF COMPLETION `� J *NUTE; 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 P, \ �'•. 4> 'v \_� Date N2 + Location 4 u V� (,_ r , 1 CEJ •- ,.., -.;�� :�' •,4'� . `4__ .,-;�,� �� �, -' � •��.•. � _ 1 C'�J _7- �c;e-J- Subdivision Name "� " " ,dot No. Sen. or RFnrkNo. Lot Size House Mobile Home _ Business Speculation ' No. Bedrooms No. Baths T No. in Family �t Garbage Disposal YES p NO p' Specifications for System: ' Auto Dish Washer YES ❑ NO (o(V-, Auto Wash Machine YES NO p G U x 1 Kri 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: System Installed byte-."��"�_'C' �r^� O Certificate of Completion C\. �`�4� 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. r , r .w .'� APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT Davie County Health Department Environmental Health Section , E���V P. O. Box 665 G Mocksville, N.C. 27028 CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED. Home Phone 4SA-9 3SCR 1. Permit Requested By I Business Phone 2. Address 3. Property Owner if Different than Above �• Det rd 1RIIe1*aM'1 S Address sox C)2g 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 IndustryOther b) Number of people 2 6. a}If house or mobile home, state size of home and number of rooms. House Dimensions 1A X 1 O Bed Rooms —Bath Rooms a 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 a urinals © garbage"disposal O lavatory a showers a washing machine dishwasher sinks 1 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. D to caner Signature OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS II w 5 d ys f rocessingk , �o 1. , -eI-L «2, �� S � le p Directions to property: 16 �e7k 9", J•l S 2c�- ILO T 3 . OCHO(6-82) - a f +A DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Box 665 Mocksville, N.C. 27028 SOIL/SITE EVALUATION Name C�A'`F'k '� Date A Address Lot Size FACTORS ARE AREA AREA 3 AREA 4 1) Topography/Landscape Position (-S� S S S <tD PS PS U U U U 2) Soil Texture (12-36 in.) Sandy, S S S S Loamy, Clayey, (note 2:1 Clay) IZ U PS 3) Soil Structure (12-36 in.) S S S Clayey SoilsPS PS PS U U U 4) Soil Depth (inches) S S PS PS U U U U 5) Soil Drainage: Internal S S S PS PS PS U U U External S S p PS PS PS U U 6) Restrictive Horizons �— 7) Available Space S S. S S PS PS PS PS U U U U 8) Other (Specify) S S S S PS PS PS PS U U U 9) Site Classification U—UNSUITABLE S—SUITABLE P Provisionally Suitable Recommendations/Comments: Described by Title Date SITE DIAGRAM 1 DCHD(6.82) `/