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P3334 Ijames Church Rd 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 �2 srl'1' llx wiz iotJ Date —7= Y� �'�i� w, .2A Location 1219f /J l� T.i i4sr�.S Cff• lC U„ L i, ; Subdivision Name Lot No. Sec. or Block No. Lot Size House Mobile Home _ '"i� Business Speculation No. Bedrooms _ No. Baths No. in Family Garbage Disposal YES ❑ NO ❑ Specifications for System: 000 ,��n '4-4 Auto Dish Washer YES ❑ NO ❑ i (� Auto Wash Machine YES ❑ NO ❑ Type Water Supply el� °£- *This permit Void if sewage systerp-de cr bei d below is not installed within 36 months from date of issue. tv � I rrJ 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 byr, ff L� (1 2- r � Certificate of Completion �` f �'" Date *The signing of this certificate shall indicate that the system descri_beld above hasbeen installed in compliance with the standards set forth in the above regulation, but shall in NO way betaken as a guarantee that the system will function satisfactorily for any given period of time. DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Box 665 Mocksville, N.C. 27028 `. SOIL/SITE EVALUATION Name.N° �/W d. Date Address 'a 2 Z Lot Size /ylOc is t�/ic L� 1VG Z 702y g FACTORS AREA 1 AREA 2 AREA 3 AREA 4 1) Topography/Landscape Position SS S S PS PS PS U U U U 2) Soil Texture (12-36 in.) Sandy, S S S S Loamy, Clayey, (note 2:1 Clay) (9 PS PS PS U U U U 3) Soil Structure (12-36 in.) S S S Clayey Soils & PS PS PS U U U U 4) Soil Depth (inches) y S S S S S PS PS PS U U U U 5) Soil Drainage: Internal ® S S S PS PS PS PS U U U U External a S S S PS PS PS PS U U U U 6) Restrictive Horizons 7) Available Space S. S S P 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 U—UNSUITABLE S—SUITABLE PS—Provisionally Suita Recommendations/Comments: ✓ �c� a �Nt Gr�7�u+� Described by .SPS-S Title `� i7A AJ Date SITE DIAGRAM W l vzt ,tz• c ya.4-Y &-F o r C- eZI S o f-77 U N O rr 04AVV4-6L pZo QL>✓o � 1 ( 1 1, i 1 1 � 1 f -T-TA-0-r s U{. n.a. DCHD(6-82) 1 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(_TA)63q 1. Permit Requested By 9rh.P n . F a p Business Phone 2. Address ;) 10 3. Property Owner if Different than Above o_-!1 /?'/� { r�P-•� Address 4. Permit To: a) Installer Alter Repair b) Privy Conventional JiL Other Type Ground Absorption c) Sub-Division Sec. Lot No. 5. System used to serve what type facility: House Mobile Homed Business Industry Other b) Number of people Q 6. a) If house or mobile home, state size of home and number of rooms. House Dimensions 1 IS) X 55 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 I urinals garbage disposal lavatory A showers washing machine dishwasher sinks ti 8. a) Type water supply: Public Private Community b) Has the water supply system been approved? Yeses No 9. a) Property Dimensions Igs )( aSb b) Land area designated to building site • 7�'d e5v 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 Slg6ature OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS Allow 5 days for processing Directions to property: tpw rvo h , I�e�'� or, ChLrc.h Ra, onL 'A� � (�D y l �,ja •nes G M16 16.821 DAVIE COUNTY HEALTH DEPARTMENT SITE EVALUATION CONSENT FORM LOCATION OF PROPERTY: / DATE RECEIVED •✓p2.f.dJl ,a/�� �. F� �� `�,' �p A 6 ,'7610 (office use only) yes no (1.) I am the owner of the above described property. ,1 yes no (2.) I am not the owner of the above described property, haaever, I j certify that I have consent from mom , ,owner !! cwnek Is nam 6u).,� obtain a site evaluation by the Health Department for the purpose of determining the suitability for a ground absorption sewage *; disposal system. yes no (3.) I hereby give consent to the authorized representative of the I� Davie County Health Department to enter upon the above described property and conduct all testing procedures necessary to determine its suitability for a ground absorption sewage disposal system. DATE SIGNATURE (4.) I hereby authorize the Davie County Health Department to release site evaluation results from the above described property to the following: (Owner QUZY Owner's designated representative Anyone requesting results DATE Only those listed below SIGNATURE a