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487 Duke Whitaker Rd r-� DAVIE COUNTY HEALTH DEPARTMENT a IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION .,*NOTE: Issued in Compliance with G.S. of. North Carolina Chapter 130 Article 13c Sewage Trreatmdntt�and Disposal Rules (10 NCAC 10A .1934-.1968) Permit Number Name _ �t !?>/� _� — Date 40e Location e. ` Y Subdivision Name Lot No. Sec. or Block No. Lot Size % i"�% � House Mobile Home r�� Business Speculation No. Bedrooms u No. Baths No. in Family — Garbage Disposal YES p NO ©— Specifications for System: Auto Dish Washer YES NO p Auto Wash Machine YES NO p Type Water Supply *This permit Void if sewage system described below is not installed within 36 months from date of issue. Improv s permit by *Contact a representative of the Davie County HealthKe tment for final insDe 'on of this system between 8:30- 9:30 A.M. or 1:00-1:30 P.M. on day of completion. on er: 704-634- 985. Final Installation Diagram: System Installed by 41)/ Ad 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 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 Date Location Subdivision Name ! Lot No. Sec. or Block No. Lot Size - `% - House Mobile Home- /f Business Speculation No. Bedrooms`-% _ No. Baths — No. in Family Garbage Disposal YES NO Specifications for System: Auto Dish Washer YES NO Auto Wash Machine YES � NO p Type Water Supply __— *This permit Void if sewage system described below is not installed within 36 months from date of issue. 4 .. f Improvemencs permit by *Contact a representative of the Davie County Health D partment for final inspection of this system between 8:30- 9:30 A.M. or 1:00-1:30 P.M. on day of completion. IeIepho Number 704-634-5985. Final Installation Diagram: System Installed by 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 µ' e t Environmental Health Section P. O. Box 665 ' Mocksville, N.C. 27028 .Y.e CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED. �� Home Phone 1. Permit Requested By t S. FFR(j Sit. Business Phone 2. Address uA F. (g x 150-3 MoC_t)Ski i 119 K)(-1 Q-10p1' 3. Property Owner if Different than Above Address 4. Permit To: a) Install Alter Repair b) Privy onventional they 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 4 6. a) If house or mobile home, state size of home and number of rooms. House Dimensions 1 a X 5 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 a washing machine dishwasher sinks 3 8. a) Type water supply: Public - Private � Community— b) ommunity b) Has the water supply system been approved? Yes No ✓ y* c Q tQ 9. a) Property Dimensions /I0 X 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? AAD 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: Turn r,q1)* o4o S1,e `► � 1d R� , Comp �o �r�ss ��c� 'TU r`f1 r i c�h�c' o r��O v �� W�`, r� k e r rRd . ;'4; DCHD(6-82) �4* DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section R O. Box 665 Mocksville, N.C. 27028 . SOIL/SITE EVALUATION Name D Date Address Lot Size FACTORS AREA 1 AREA 2 AREA 3 AREA 4 1) Topography/Landscape Position S S S PS PS U U U U 2) Soil Texture (12-36 in.) Sandy, S S Loamy, Clayey, (note 2:1 Clay) PS PS `tT U U U 3) Soil Structure (12-36 in.) S S S Clayey Soils PS PS U U U 4) Soil Depth (inches) SS S "SPS PS U U LTJ— U U 5) Soil Drainage: Internal S S S S - "ff PS PS U U External S S p k> PS PS U U U 6) Restrictive Horizons 7) Available Space S S g PS PS U U U U 8) Other (Specify) S S S S PS PS PS PS U U U U 9) Site Classification U, UNSUITABLE S—SUITABLE PS—Provisionally Suitable Recommendations/Comments: Described byTitle Date A SITE DIAGRAM DCHO(6-82)