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P5135 Davie Academy Rd DAVIE COUNTY HEALTH DEPARTMENT j IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION Issued-in Compliance with G.S..of North Carolna,Chapter 130 Article. 13c wNASewage'Treatment and Disposal Rules.(10 NCAC 10A .1934-.1968) Permit' Number Name ///1: /%'� ��/��G' �� >>.,'��i' i Date MG 5135 °ter Location /r.. .r` //"�✓' / t//i�i/' r /�r" � — /�%kr / tYJ m%' ,f`�/ Subdivision Name Lot No. Sec: or Block No. Lot Size W46Y 1'Tr7' House ` Mobile�;Home _� Business Speculation I No. Bedrooms ' No, Baths _ No. in'Family .� , Garbage-Disposal YES .❑ ',No ii• Specifications for,System: Auto Dish Washer YES ,E] NO . Auto.Wash Machine YES ElN0 Type,Water.'Supply — *This'permit Void if sev✓age system described'below is`not installed within 36 months from-date of issue. ' ,.• it .�_ ' 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\ •v 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 betaken as a guarantee that the system will,function satisfactorily for any given period of time. . `j APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT U Davie County Health Department R 3 0 Environmental Health Section c v�O.MA P. 0. Box 665G`` VO Mocksville, N.C. 27028 CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED. Home Phone 1. Permit Requested B Business Phone 2. Address 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 Sec. Lot No. 5. System used to serve what type facility: House Mobile Home,4:n'_Business Industry Other b) Number of people J 6. a) If house or mobile home, state size of home and number of rooms. House Dimensions 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) Number and type of water-using fixtures: l commodes urinals garbage disposal l lavatory ___? showers Z washing machine dishwasher sinks -/ 8. a) Type water supply: Public G Private-Community b) Has the water supply system been approved? Yes No 9. a) Property Dimensions .�o 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 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: dos �� age-- 15-7 { DCHD(6-82) DAVIE COUNTY HEALTH DEPARTMENT Environmental Hearth Section P. O. Box 665 Mocksville, N.C. 27028 SOIL/SITE EVALUATION Name /�! � Date Address Lot Size /&dc; FACTORS AREA 1 AREA 2 AREA 3 AREA 4 1) Topography/Landscape Position S S S S U" PS PS PS 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 U 3) Soil Structure (12-36 in.) S S S S Clayey Soils (ff§) PS PS PS U U U 4) Soil Depth (inches) S S S PS PS PS U U U 5) Soil Drainage: Internal S S S t) PS PS PS U U U U External S S S d' PS PS PS U U U 6) Restrictive Horizons 7) Available Space S S S `b PS PS PS U U U 8) Other (Specify) S S S S PS PS PS PS U U U U 9) Site Classification R , U—UNSUITABLE S—SUITABLE PS Provisionally Suitable Recommendations/Comments: Described by Title , � Date100, SITE DIAGRAM �j DCHD(6.82)