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134 Livengood Rd DAVIE COUNTY HEALTH DEPARTMENT] k IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION ,*,NOTE: Issued in t✓o4pliance with G.S. of North Carolina Chapter 130 Article 13c Sewage Treatment and Disposal Rules (10 NCAC 10A .1934-.1968) Permit Number � � V Name�'* � '— �� � ��� Date Location �'-., .� /%, ,✓�/ ✓,? p ✓ n1�_. /moi/"% ,r,� 'i✓ , r� 1:5 i� yr 6Q �_. Subdivision Name t o. Sec. or Block No. Lot Size ��� e2 House Mobile Home _ Business __ Speculation No. Bedrooms `– No. Baths 4 No. in Family Garbage Disposal YES p NO g--- Specifications for System: Auto Dish Washer YES NO Auto Wash Machine YES NO Type Water Supply li'/�/ -- v%"•�`ii"y 'This permit Void if sewage system described below is not-i6stalled,within.3(5months from date of issue. L. I � , Improvements permit by`— -,- �•, *Contact a,-representative of the Davie County Health Departmenifor final inspection of this system between 8:30- 9:30-:X-M. or 1:00-1:30 P.M. on day of completion. Telephone Number: 704-634-5985. �`� Final Installation Diagram: System Installed by J� 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. DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section • R 0. Box 665 Mocksville, N.C. 27028 SOIL/SITE EVALUATION Name P Date Address Lot Size���Je�9 FACTORS AREA 1 AREA 2 AREA 3 AREA 4 1) Topography/Landscape Position S S S PS PS U U 2) Soil Texture (12-36 in.) Sandy, � � S S Loamy, Clayey, (note 2:1 Clay) PS PS U U U 3) Soil Structure (12-36 in.) S S S S Clayey Soils ® PS PS U U U 4) Soil Depth (inches) ( S S ' C5 PS PS U U U U 5) Soil Drainage: Internal S S S S <29D -15PS PS U U U U External S® S S S PS PS U U U 6) Restrictive Horizons 7) Available Space S S. S S c� 1 J""' 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 ` Title Date SITE DIAGRAM �L DCHD(6-82) APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT Davie County Health Department Environmental Health Section , r P. 0. Box 665 V( Mocksville, N.C. 27028 CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED. ---r� Home Phone 19'd- -Aw)I 1. Permit Requested By Business Phone »h'q 103 2. Address R , 9, gox X16R %a R, , C1®Q, a>Ooh 3. Property Owner if Different than Above Address 4. Permit To: a) Install ✓ Alter Repair b) Privy Conventional/Other Type Ground Absorption c) Sub-Division S c. Lot No.�g 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 vllr x 3$ Bed Rooms—Bath Rooms_Den w/Closet 1 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 2 washing machine 1 dishwasher sinks 8. a) Type water supply: Public Private ✓ Community b) Has the water supply system been approved? Yes/No 9. a) Property Dimensions— b) imensions R�v b) Land area designated to building site rids c) Sewage Disposal Contractor 10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve? /VO What type? This is to certify that the information is correct to the best of my knowledge. d Date Owner Signature OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS Allow 5 days for processing Directions to property: -.�,r�►h Moc,ksv itl¢, �0►5�' ofl L4 on Chug& RdA Dight on 1.Villio-m6 R4 {lrl�,bi le flame, on 810111t - O ( fi 3 Gy Fick Ch�r4h (fid, DCHD(6-82)