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P5633 Cherry Hill Rd DAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION ',.NOTE: tssued in Compliance with G.S. of North Carolina Chapter 130 Article 13c Sewage Treatment and,Disposal Rules (10 NCAC 10A .1934-,1968) Permit Number • \ f Named����n:�.������l,�fa .�15`, `err .I�;f ,..� ate /, ; �' N2 5633 r`;•, r ..- ~ 1. + -^ - `Location I /- %t✓` ,IA6`1 %:.u, .c ',7' :.1 Subdivision Name Lot No. Sec. or Block No. Lot Size House Mobile Home _1'�J Business Speculation No. Bedrooms No. Baths No. in Family _ Garbage Disposal YES .fl NO (q Specifications for System: Auto Dish Washer YES p NO Auto Wash Machine 'YES ©''NO p Type Water Supply r *This permit Void 'f sewage system described below is not installed within 36 months from date of issue. � � A{A _SIV 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 by ................Certificate of Com letion � �Q _ Date *The signingf this ctertificate`Hall indicate that the system described above has been installed in compliance with the tandards 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 8 Davie County Health Department ct �JV� Z Environmental Health Section RL P. O. Box 665 w I 1 Mocksville, N.C. 27028 CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED. ome Phone 637 - 37�� //,,rr "A_x,-4Ae_4 ,r4�usiness 138- 10 (0 1. Permit Request�jd By Gv• Phone o� 2. Address /�-�� s c� •S �� 3. Property Owner if Different than Above Address _q/,5 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 Homes IndustryOther b) Number of people 6. a}If house or mobile home, state sizehomehome and number of rooms. 7 House Dimensions a4 x 0 Bed Rooms 3 Bath Rooms Den w/Closet / b) If Business, Industry or Other, State: of persons served What type business, etc. Estimate amount of waste daily (24 hours) pr 7. Number and type of water-using fixtures: / commodes urinals N/A' garbage disposal lavatory N A- showers washing machine dishwasher N N sinks 8. a) Type water supply: Public Private ✓ Community b) Has the water supply system been approved? Yes No 9. a) Property Dimensions Pe• 9az&z4J —a3O.377 AM.7JY /3/6. 7SXa57, 7 b) Land area designated to building site c) Sewage Disposal Contractor 7 10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve? 1 166 What type? This is to certify that the information is correct to the best of my knowledge. 7- d S Date (3agw Signature OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS Allow 5 days for processing Directions to property: r1tt -7k -� ,9- P DCHD(6-82) 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. O. Box 665, Mocksville, N.C. 27028 Davie County Health Department Environmental Health Section Site Evaluation Consent Form LOCATION OF PROPERTY: DATE RECEIVED (office use only) G� yes 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 �` �CVz Zl�ae - owner to obtain a owner's name site"evaluation by the 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 property and conduct all testing procedures as necessary to determine its suitability for a ground absorption sewage treatment and disposal systema D � r SIGN ATU�tE��i.c�nz•- 4. 1 hereby authorize the Davie County Health Department to release site evaluation results from the above described property to the following: — Owner only - Owners designated representative nyone requesting results i?AOnly those listed below 4P d bATE SIGNATURE �� DCHD(11/84) c:t� 9 od d v Oo e, y 91.0 3 1( a'r fid`'yc ,3 7 ,y"a z1Yr f; � ( 9.20 Ard' = 50.0 y 5 6.3 0 A c. -. -� co ` N 'S /t i (E i.. A 8 8.69 00 A. ,0 R &Jam �2 .96" A 01.fi9 +' il y C7 Vit, d 4 A P P I N G DAVIE COUNTY.HEALTH DEPARTMENT Environmental Health Section. P. O. Box 665 Mocksville, N.C. 27028 SOIL/SITE EVALUATION / Name Date Address Lot Size FACTORS AREA 1 AREA 2 AREA 3 AREA 4 1) Topography/Landscape Position ® � � (05 U U U U 2) Soil Texture (12-36 in.) Sandy, S S S Loamy, Clayey, (note 2:1 Clay) AP ��Op U U U 3) Soil Structure (12-36 in.) S S Clayey Soils 4) Soil Depth (inches) S U U 5) Soil Drainage: Internal PS ® (om' U U U External S S __.— S U U 6) Restrictive Horizons 7) Available Space PS PS PS PS U U U U 8) Other (Specify) S S S S PS PS PS PS U U U Y- 9) Site Classification U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable Recommendations/Comments: Described by —� �'�� Title 1 ��'� Date SITE DIAGRAM Y - . ',..DCHD(6.82) '