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945 Hwy 64W4V1zdri DAVIE COUNTY HEALTH DEPARTMENTr _ IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION 'NOJE: 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 ^Nam e 7 <' Date /,C�7J/xp NO �l. Location Subdivision Name Lot No. Sec. or Block No. Lot Size %'f%f House Mobile Home _ Business Speculation No. Bedrooms No. Baths_ No. in Family._ Garbage Disposal YES ❑ NO ©- Specifications for ystem: Auto Dish Washer YES NO ❑ �"/ Auto Wash Machine YES NO ❑ a �, 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 +piagram: SysteT 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 lie 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 Environmental Health Section P. O. Box 665 Mocksville, N.C. 27028 CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED. Home Phone 1. Permit Request d Bye `� ' Vv t7C �� Business Phone /3`( -tiS 2. Address X3a-;t 13 /�% e r (z p �G�� C• Z? d 3. Property Owner if Different than Above 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: Housed Mobile Home Business Industry Other b) Number of people 2- 6. 6. a} If house or mobile home, state size of home and number of rooms. House Dimensions Bed Rooms .3 Bath Rooms Z 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 Z washing machine dishwasher sinks _TX1 8. a) Type water supply: Public Private Community b) Has the water supply system been approved? Yes Nolf�_ 9. a) Property Dimensions 4�" b) Land area designated to building sitef%C c) Sewage Disposal Contractor 10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve? /V O What type? This is to certify that the information is correct to the best of my knowledge. W2&�, — 1, v Date dwner Signature OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS Allow 5 days for processing Directions to property: DCHD (6-82)' Name Address — DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Box 665 Mocksville, N.C. 27028 SOIL/SITE EVALUATION Date l� FA�Tf1RC ARFA y Lot Size��' APPA 9 ARFA 3 APPA A I) Topography/ Landscape Position ® � Cw dip U U U U ') Soil Texture (12-36 in.) Sandy, Loamy, Clayey, (note 2:1 Clay) S S S U U U 1) Soil Structure (12-36 in.) Clayey Soils S /6 S Q U U S U I) Soil Depth (inches) I5 P S (rJJ (U U �) Soil Drainage: Internal U External U S S �) Restrictive Horizons Available Space PS PS PS fS U U U U 1) Other (Specify) S PS S PS S PS S PS U U U U 1) Site Classification U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable Recommendations/Comments: Described by it a Date SITE DIAGRAM ky DCHD (6-82) h-