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P3895 Indian Hills DAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION ;N. E( Issued'in Compliance.with G.S. of North Carolina Chapter 130..Article 13c 1TS Sewage Treatment and Disposal Rules (10 NCAC 10A .1934-.1968) Permit Number V Name Dates /<a Location rl /✓ i /f r' Subdivision Name Lot No. Seca or Block No. Lot Size ' �i%'�r _ House `"�J Mobile Home _ Business Speculation No. Bedrooms -r No. Baths y'r` No. in Family-- .Garbage amily _..Garbage Disposal YES ❑ NO p' ❑ Specifications for System: Auto Dish Washer YES NO Auto Wash Machine YES NO ❑ Type Water Supply *This permit Void if sewage system described below is not installed within 36 months from date of issue. a t J i 1 Improvements permit by cr *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 —2/ (.,t5 Certificate of Completion Dates *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. j DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. 0. Box 665 Mocksville, N.C. 27028 SOIL/SITE EVALUATION Name— Date `s 1 Address Lot Size Awa FACTORS AREA 1 AREA 2 AREA 3 AREA 4 1) Topography/Landscape Position S S S S C. PS PS U U U 2) Soil Texture (12-36 in.) Sandy, ARD S S S Loamy, Clayey, (note 2:1 Clay) &0? PS PS U U U U 3) Soil Structure (12-36 in.) S S S Clayey Soils �� PS PS U U U U 4) Soil Depth (inches) S S PS PS U U U 5) Soil Drainage: Internal S S S Ap�s PS PS U U U U External S S S S PS PS PS PS U U U U 6) Restrictive Horizons 7) Available Space S 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 - U—UNSUITABLE S—SUITABLE PS—Provisionally Suitabl Recommendations/Comments: Described by / Title Date � SITE DIAGRAM DCHD(6-82) 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. h �j Home Phone 1. Permit Req ested By �w1AL�'r-A- ROCLY1�t"L Business Phone SRrn�- 2. Address 3. Property Owner if Different than Above Address 4. Permit To: a) Install If" 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 Home Business 1-00 IndustryOther b) Number of people 1 00 6. a) If house or mobile home, state size of home and number of rooms. House Dimensions S �) �a01(,3 a Bed Rooms 3 Bath Rooms a 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 3 urinals garbage disposal lavatory `3 showers 1 washing machine dishwasher 1 sinks 1 8. a) Type water supply: Public ko"' Private Community b) Has the water supply system been approved? Yes '� No 9. a) Property Dimensions 'leg C S b) Land area designated to building site c) Sewage Disposal Contractor n-'(Ky Jost C f 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: 4 b0trl P poa ��... DCHD(6-82) � D � K � �..._.... ;. 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