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110 Liberty Circle"'r r..w.-.x:6.1.♦ .� "•yq:'t.iw...!<.. `::..:♦ .'.MrV"'•. . ... .... t 1 .S .. , . ... ... ... s .3.. wY `//'�� 4 '1.1,y^S'k,1'+?wtP.- 'i',"t"q.:jk. .riff I'F'r. ..a.. .:.J3� j"1;-._I.-Jr.� , '_t. ;-{: l'•...:'. n-pop pp Q 4�A+ ,r I F C . Z DAVIE COUNTY .HEALTH DEPARTMENT 1 ;_ IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION *NOTE: Issued in Compliance with G.S. of North Carolina Chapter 130 Article 13c Sewage TreatmentandDisposal Rules (10 NCAC 10A .1934-.1968) Permit Number Name .` r�✓- � ;�� �� n.7 PDateN2 5 Location — �7 AIL,- J �/' ! Subdivision Name Lot No. Seca or Block No. Lot Size House Mobile Home _ Business Speculation No. Bedrooms No. Baths_ Z _ No. in Family Z Garbage Disposal YES C] NO Specifications for Syste Auto Dish Washer YES NO L i /� Auto Wash Machine YES NO p Type Water Supply _ q�GU.Y.�i�'� *This permit Void if sewage system described below is not installe ithin 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 Ins aIle by Certificate of Completion Date Date igning of this certificate shall indicate that the system described above has been installed in compliance with andards set forth in the above regulation, but shall in NO way be taken as a guarantee that the system will function ctorily for any given period of time. • APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT Davie County Health Department h��EtVEDJ01 L Environmental Health Section R 1 Gid P. O. Box 665 Mocksville, N.C.27028 CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED. Home Phone 1. Permit Requested By 13°L CAp.j Ste-- Ca-44we41C•- Business Phone 2. Address R+4, $% UK m4eX6%;##c hL Z.1%2-t 3. Property Owner if Different than Above _treA &tV.s 1 Be".J- 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: House-!Ll-Mobile Home Business IndustryOther b) Number of people ^ 6. ay If house or mobile home, state size of home and number of rooms. House Dimensions Bed Rooms Z 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 v No 9. a) Property Dimensions 1co X 206 !Ftet 4. b) Land area designated to building site c) Sewage Disposal Contractor -Adk �•+r+-� 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. X '7— 1"1-89 Date Owne Signature OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS Allow 5 days for processing Directions to property: (om1S -T• uk. Gtla.D51d•a. gam- - IaA or, 1eF-v (_Qa�el eRtoee�s) �f• RH.� OCHD(8.82) 46 ' DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section. P. O. Box 665 Mocksville, N.C. 27028 SOIL/SITE EVALUATION Name Date v r Address Lot Size leo- ail) FACTORS AREA 1 AREA 2 AREA 3 AREA 4 1) Topography/Landscape Position0 S S PS'" S PS PS U 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 3) Soil Structure (12-36 in.) S S S Clayey SoilsPS PS U Com' U U 4) Soil Depth (inches) �F �-v PS PS U U U 5) Soil Drainage: Internal S S &P PS PS U U U U External S S S S PS PS U U U 6) Restrictive Horizons 7) Available Space S S S PS PS 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 Suitable Recommendations/Comments: Described by '!% ���z// Title —��� - - - Date SITE DIAGRAM n � DCHD(6-82) _�/ ' r DAVIE COUNTY HEALTH DEPARTMENT ENVIRONMENTAL HEALTH SECTION SITE EVALUATION CONSENT FORM 1. Complete the form below and return to the Davie County Health Department. 2. Carefully follow the procedures as outlined in the enclosed "Information Bulletin." NOTE: THE ABOVE MUST BE COMPLETED BEFORE A SANITARIAN WILL BE ABLE TO BEGIN THE REQUESTED EVALUATION. DETACH HERE AND RETURN TO: Davie County Health Department, Environmental. Health Section, R O. Box 665, Mocksville, N.C. 27028 Davie County Health Department Environmental Health Section Site Evaluation Consent Form LOCATION OF PROPERTY: DATE RECEIVED (office use only) eyes no 1. 1 am the owner of the above described property. yes no 2. 1 am not the owner of the above described property, however, I certify that I have consent from owner to obtain a owner's name site evaluation by the Davie County Health Department for the purpose of determining the suitability for a ground absorption sewage treatment and disposal system. des no 3. 1 hereby give consent to the authorized representative of the Davie County Health Departmentto enter Upon the above described property and conduct all testing procedures as necessary to determine its suitability for a ground absorption sewage treatment and disposal system. DATE �— SIGNATURE 4. 1 hereby authorize the Davie County Health Department to release site evaluation results from the above described property to the following: — Owner only — Owners designated representative Anyone requesting results — Only those listed below DATE SIGNATURE DCHD(11/84)