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6554 Hwy 801Sa.,�ua .:,.:,�.�=:.,, �, .. ..w4. - ,.t ��ti...=�- �4 .:u. �...... •'. .... .., . _ . . ,� f i .. .� . ^�... .. S. , a .- ,-.._ ,. a... s ... � .. , ., .., .. ... -y DAVIE COUNTY HEALTH DEPARTMENT A IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION "NOTE: Issued in Compliance with G.S. of North Carolina Chapter 130 Article 13c ;Me,Treatment and Disposal Rules (10 NCAC 10A .1934-.1968) Permit Number Name ' l„+�,�1 Dated .� Location _1cV/5,-"_i Subdivision Name Lot No. Sec. or Block No. Lot'Size ,/_w 11C• House Mobile Home k-- Business Speculation No. Bedrooms No. Baths _,�— No. in Family Garbage Disposal YES ❑ NO 8-- Specifications for System` � Auto Dish Washe�� YES V NO ❑� rv— Auto Wash Machine YES NO-E]/Dv " Jc 10 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 Diagram: System 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 be 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 J ` 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 By /�06E4 7' % b00-1 /: J Business Phone 2. Address 9ou`rF V 00K / F'l - S 49,QC es,I j«le- 6zd- a7oa'1� 3. Property Owner if Different than Above SA�� X Address 4. Permit To: a) Install v 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 IndustryOther b) Number of people 6. a) If house or mobile home, state size of home and number of rooms. House Dimensions 5� X q q Bed Rooms_3 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 ho 7. Number and type of water -using fixtures: commodes e_1 lavatory �-- dishwasher urinals showers sinks garbage disposal washing machine l 8. a) Type water supply: Public Private Community b) Has the water supply system been approved? Yes No 9. a) Property Dimensions 1:7-- Ac 2E'_ 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 cgr�ectpo tI)e best of 9Ky "owledge. Date Owner Signature OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS Allow 5 days for processing Directions to property: DCHD (6-82) "C. Address GA (`Tn R C DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Box 665 Mocksville, N.C. 27028 SOIL/SITE EVALUATION Date 1/4X Lot Size Ave AREA i AREA 7 AREA R ARFA A Topography/ Landscape Position S S S S Com' PS PS PS U U U U �) Soil Texture (12-36 in.) Sandy, S S S Loamy, Clayey, (note 2:1 Clay) 4A� PS PS PS U- U U U 1) Soil Structure (12-36 in.) S S S Clayey Soils PS PS PS `tT U U U 1) Soil Depth (inches) S S S PS PS PS PS U U U Soil Drainage: Internal S S S S PS PS PS U U U External S S S pS PS PS PS U U U 1) Restrictive Horizons �. Available Space S S S PS PS PS PS 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—ProvlsionallySuitable Recommendations/ Comments: le Described by SITE DIAGRAM DCHD (6-82) Title �./ DateZZ