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1147 Baileys Chapel Rd _ DAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENTS PERMIT AND CERTIFICATE -OF COMPLETION `NOTE: Issued in'Compliance with G.S. of North Carolina.Chapter 130 Article. 13c Sewage.Treatment and Disposal Rules (10 NCAC 10A .1934-.1968)- Permit Number Names ��/ 6�, '' s Dates .� ® 3292' Locat j. Subdivision Name Lot No. Sec. or Block No. Lot Size House l Mobile Home Business Speculation No. Bedrooms:`- -No: Oaths' No. in Family Garbage Disposal .' .YES' NO [ -" Specifications for System:, Auto Dish Washer YES NO ❑ ` r r t ,,. •Auto Wash MachineYES 4,I NO I /� ' Type ,Water.Supply rel✓rr; i _— f *This permit Void if sewage'syst m described below is not installed within 36 months from date of issue. • ` it it • _. i Improvements permit byI' t` !-t' *Contact a representative of.the Davie*'bounty;,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 In Diagram: ' ' System Installed by1.^-tom • �- i Vii ' . , - 1 - 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 O. Box 665 Mocksville, N.C. 27028 SOIL/SITE EVALUATION Name �'F ©<<��� Date Address1009 � S —// �� _ i Da Lot Size FACTORS AREA 1 AREA 2 AREA 3 AREA 4 1) Topography/Landscape Position S S S S S PS PS U U U 2) Soil-Texture (12-36 in.) Sandy, ,..-S� S S Loamy, Clayey, (note 2:1 Clay) -- PS PS U U U U 3) Soil Structure (12-36 in.) S S S Clayey Soils PS �PS PS PS U U 4) Soil Depth (inches) S S S S _ PS PS 5) Soil Drainage: Internal S S PS ( PS PS U U External S S S S PS PS U U U U 6) Restrictive Horizons 7) Available Space S S 0 -P PS PS U U U U 8) Other (Specify) S S S S PS PS PS PS UU U U U 9) Site Classification J U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable Recommendations/Comments: Described by Title �T/� Date SITE DIAGRAM J SSD / DCHD(6-82) i APPLICATION FOR SITE E.UAL.IJt�.-',O I/I1riPf3OVE:sk."'�l,\1T S PEFINIAT Davie-ColAnty Health Department • Environm6)7'aI Health Section R 0. Box, 665 klocksville, N.C. 27028 CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMEN i S PERMIT HAS BEEN ISSUED. Home Phone_ 99k- 9 z- 1. Permit Requestq By Business Phone -2-- T f:� 2. Address.- 3. ddress.3. Property Owner if Different than Above _ a i✓ __11'1_r�T�1i �/✓ — Address Wit_✓-�/v' e .— di. Permit To: a) InstallL�Alter Repair-- b) Privy__Comrentional Z Other Type.., Ground Absorption c) Sub-Division Lot No._-. 5. System used to serve what type facility: House-_ Mobile Home .01�Business Industry,_.Other__— b) t•lUrnber of people Cf U r r g_� 6. fa) ll 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, Stnte: Number of persons served Whit type business, etc. _— Estimate amount of waste daily (24 hours)_ 7. Number and type of water-using fixtures: commodes �� urinals _ garbage disposal lavatory Y showers—_ 2-- washing machine—, dishwasher _—._ sinks 8. a) Type water supply: Public �rivate _..Community�_..� b) Has the water supply system been approved? Yes_—N 9. a) Property Dimensions C 3__. b) Land area designated to building site /00 c) SAwage Disposal Contractor r- 10. Do you anticipate any additions or expansions of the facility this sewa ge system is intended to serve? — What t,1le? This is tocerti that the information is correct to th(: best of my knowledge. at owner Signature OWNER ISSOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS Allow 5 days for processing Directions topropery ri d �o• -- - ------ jJ^ �� �.S'/-�x(0/7 J v r4 011 � OCHD(6-32) E rr l i . d �h 3i 1 ry �Vol " f4t V1 i{ I ,Fp� "1 , ' 1Y�1 �1;.. l��i':�rG. ��c'9 ' {1 /1� I • i �..c: X91 11 Ob air' ° k , �,, � -fir;•• _-'' rt �•Y!c.�p�(! LA L c + a .1' G cD i0 u•� � 1.1 o1 ')b 0c• t14 1�5) 4�+ ( N UJ \ r° t N