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6570 Hwy 801S 2 p 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 Date 141a "�:�4 Location Subdivision Name Lot No. Sec. or Block No. Lot Size House Mobile Home _ Business Speculation No. Bedrooms�� No. Baths No. in Family Garbage Disposal YES p NO ET---- Specifications for Sys em: Auto Dish Washer YES NO Auto Wash Machine YES,� NO Type Water Supply r'A','�`-__ _ � *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 by „s ,0 y J o n . � 5 Certificate of Completion yv�j��_J 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 Environmental Health Section P. 0. Box 665 Mocksville, N.C. 27028 SOIL/SITE EVALUATION Name Date Address LotSize FACTORS AREA 1 AREA 2 AREA 3 AREA 4 1) Topography/Landscape Position S S S S PS PS PS U U U 2) Soil Texture (12-36 in.) Sandy, S S S S Loamy, Clayey, (note 2:1 Clay) PS PS PS U 'U U U 3) Soil Structure (12-36 in.) S S S Clayey Soils PS PS PS PS U U U U 4) Soil Depth (inches) S S S S PS PS PS U U U U 5) Soil Drainage: Internal S S S S / u PS PS PS U U U External S S S S PS PS PS U U U U 6) Restrictive Horizons 7) Available Space 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 U 9) Site Classification .75,– U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable Recommendations/Comments: Described by -/O ,Z�Z Title Date�,�� SITE DIAGRAM S DCHD(6-82) APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT IJS— Davie County Health Department Environmental Health Section R O. Box 665 Mocksville, N.C. 27028 CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED. > ,� �`�� Home Phone 1. Permit Requested B ���/�✓��� � �z � Business Phone 2. Address 3. Property Owner if Different than Above Address 4. Permit To: a) InstallIter Repair b) Privy Conventional `�ther Type Ground Absorption c) Sub-Division /-2 1 Sec. Lot No. 5. System used to serve what type facility: House Mobile Home — 4—'Business—IndustryOther b) Number of people 6. a) If house or mobile home, state size of home and number of rooms. House Dimensions 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 dishwasher sinks 8. a) Type water supply: Public Private Community b) Has the water supply system been approved? Yes �No 9. a) Property Dimensions r1 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 iT Owner Signature OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS Allow 5 days for processing Directions to property: � t ) DCHD(6-82)