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363 Cana Rd a ;_�y,��,'S a;�i i-. .:.'.F ;:.i=.a.�..-.w....�..,i, ,.:'+ .y .. :,.e.Y i•.3 i�4w -.t ._ w .s...c.. ..F-m:'.. �;;o''._. . .- ', ., ,yam - ,i _ -, ... - ' - DAVIE COUNTY HEALTH 'DEPARTMENT J 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 a Date _.� 9 N2 0 Location � �`"��. �� -.. � ; ,. �..1 -�� .� C`� .b .R> a�t 7.1�( (` Z,��.` .� U4 ['' U� \V `\��\C�. `�.�°.�•-<'#. \\�- '.-) �.?.r i Jam- � -.1.!i.(.:� "?Jrfi. ,^c.. f Subdivision Name Lot Ni . Sec. or Block No. Lot Size �� House Mobile Home _ t'»' Business Speculation No. Bedrooms La;No. Baths ~� No. in Family t Garbage Disposal YES p ` NO ©' Specifications for System:- Auto Dish Washer .. YES lj NO fl / v o Auto Wash Machine YES NO'C] Type Water Supply �. s, *This permit Void if sewage system described below is not installed within 36 months from date of issue. 1. A__3 U Improvements permit by *Contact a representative of the Dave .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.,Tlephone Number: 704-634-5985. Final Installation Diagram: System Installed by Certificate of Completion Date �Z5 *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 IED Environmental Health Section P. 0. Box 665 Mocksville, N.C. 27028 CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED. Home Phone 7�-;� -e2 6,92 1. Permit Requested By path eo'-1,2I CI Business Phone 2. Address A399 4ve. klj1 0�u- 5kk;y �,�.t^. , d„V adj” RAF' �2M ,zip .27// 3. Property Owner if Different than Above � n );MK-j� M • Address,52A C.1&r0u1 s'*. , -hm 0_�S U Ku •C. 7—Q 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 Homed Business— usiness 6 ��(AA,et e) Industry Other b) Number of people �- 6. a) If house or mobile home, state size of home and number of rooms. House Dimensions 2'?, X G D ` 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 I dishwasher sinks A 8. a) Type water supply: Public Private Community b) Has the water supply system been approved? Yes ✓' No 9. a) Property Dimensions L83-34 X 2 r12•N7 2C 1 R5;'/�9 x 2d7,97 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. Date Owner Signature OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS Allow 5 days for processing Directions to property: � � f DAVIE COUNTY HEALTH DEPARTMENT ENVIRONMENTAL HEALTH SECTION SITE EVALUATION CONSENT FORM 1. Complete the form below and return to the Davie County Health Department 2. Carefully follow the procedures as outlined in the enclosed "Information Bulletin." NOTE: THE ABOVE MUST BE COMPLETED BEFORE A SANITARIAN WILL BE ABLE TO BEGIN THE REQUESTED EVALUATION. DETACH HERE AND RETURN TO: Davie County Health Department, Environmental Health Section, P. 0. Box 665, Mocksville, N.C.27028 Davie County Health Department Environmental Health Section Site Evaluation Consent Form LOCATION OF PROPERTY: DATE RECEIVED SU5T P P&-r 19,a-\U (office use only) yes no 1. 1 am the owner of the above described property. yes no 2. 1 am not the owner of the above described property, however, I certify that I have consent from , owner to obtain a owner's name site evaluation by th Davie County Health Department for the purpose of determining the suitability for a ground absorption sewage treatment and disposal system. yes no 3. 1 hereby give consent to the authorized representative of the Davie County Health Department to enter upon the above described propertyand conduct all testing procedures as necessary to determine its suitability for a ground absorption sewage treatment and disposal system. DATE IGNATURE 4. 1 hereby authorize the Davie County Health Department to release site evaluation results from the above described property to the following: Owner only -7-,Owners designated representative Anyone requesting results _ Only those listed below DATE QGNATURE DCHD(11/84) r. DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Box 665 Mocksville, N.C. 27028 SOIL/SITE4EVALUATION c� Name ) �� Qt-o. c�w �Iw Date �" ra Address S n^ Lot Size - FACTORS E AR 2 AREAS AREA 1) Topography/Landscape Position S S S S PS PS PS PS U - U U U 2) Soil Texture (12-36 in.) Sandy, Loamy, Clayey, (note 2:1 Clay) P S, PS U U 3) Soil Structure (12-36 in.) Clayey Soils ' PS < �p U U U U 4) Soil Depth (inches) U U U 5) Soil Drainage: Internal PS P P U External S ��" �P� PS PS, 6) Restrictive Horizons 7) Available Space S S S PS U U. 8) Other (Specify) S S S S PS PS PS PS U U 9) Site Classification U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable Recommendations/Comments: Described by Title DatQ-26" g SITE DIAGRAM DCHD(6-82)