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4418 Hwy 801S DAVIE COUNTY HEALTH DEPARTMENT' . w1 IMPROVEMENTS PERMIT AND-CERTIFICATE OF- COMPLETION `NOTE: Issued in Compliance with G.S. of- North Carolina Chapter-130Article •13c Sewage Treatme6t and Disposal Rules (1.0 NCAC 10A .1934-.1968.) Permit Number. Name � - ,., . ,u; Date �— : � Location .. j�l �\ J ` - ,.f-Y ry � •-.- `r'R`•+ C� �. - `.'�J'} ; �:4^_i:'a1.r."A `..40 SubdiJision Name Lot No. Sec. or Block No. Lot :Size House; ,Mobile Home kool Business Speculation No. Bedrooms No. Baths _ No. in Family Garbage Disposal YES p' NO [ Specifications for System: Auto Dish Washer YES V NO .❑ o . , = Auto Wash Machine YES NO, ❑ ^^d �t''�x. Type Water,Supply K7 "This permit Void if sewage system de'sc'ribed .below is not.installed,within 36 months from date of issue. s. 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: Tel a Number: 704-634-5985. Final Installation Diagram: PSyteInstalled by Certificate of Completion Date 'The signing of this certificate shall indicate that the system des cribed,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 Environmental Health Section P. 0. Box 665 Mocksville, N.C. 27028 CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED. Home Phone —�9E- 7/3-9 1. Permit Requested By ��� i ��' Business Phone 2. Address f 6 ow A C. 3. Property Owner if Different than Above S Address /ems 2 �ox n�e NC . 4. Permit To: a) Install Alter Repair b) Privy Conventional ether Type Ground Absorption c) Sub-Division Sec. Lot No 5. System used to serve what type facility: House Mobile Home Business Industry Other b) Number of people 6. a) If house or mobile home, state size of home and number of rooms. House Dimensions /b( 20 Bed Rooms Z Bath Rooms Den w/Closet t 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 Z urinals garbage disposal lavatory 2 showers Z washing machine / dishwasher sinks ! 8. a) Type water supply: Public ✓ Private Community b) Has the water supply system been approved? Yes No 9. a) Property Dimensions LC c r e s b) Land area designated to building site a C- r P_ C) Sewage Disposal Contractor 10. Do you anticipate any,ad itions or//expansions of the facility this sewage system is intended to serve?& �eS What type? I?v, 0 14F 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: JWY 6, 5t -gyp �Of SoLtI% Oh a 9 e- a _{ r "- Ss -r,e l d Cso L..t.t, e h ,, e d s ..�� DCHD(6-82) y 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, P. 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) yes no 1. 1 am the owner of the above described property. yes no 2. 1 am not the owner of the above d/escribed property, however, I certify that I have consent from s,� � , 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. es no 3. 1 hereby give consent to the authorized representative of the Davie County Health Department to enter upon the above described property and conduct all testing procedures as necessary to determine its suitability fora 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 7 Owners designated representative —Anyone requesting results — Only those listed below DATE SIGNATURE r DCHD(11/84) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section R O. Box 665 Mocksville, N.C. 27028 SOIL/SITE EVALUATION L( Q NameDate Address Lot Size FACTORS AREA AREA AREA 3 AREA 4 1) Topography/Landscape Position S S PS PS U U U U 2) Soil Texture (12-36 in.) Sandy, S S Loamy, Clayey, (note 2:1 Clay) PS PS PS U U U 3) Soil Structure (12-36 in.) S S Clayey Soils S PS PS U U U U 4) Soil Depth (inches) S S PS PS U U U U 5) Soil Drainage: Internal S S S P <IDN PS PS U U U External S S P < J PS PS U U U U 6) Restrictive Horizons 7) Available Space CC) S S PS PS PS PS U U U U 8) Other (Specify) S S . S S PS PS PS PS U U U 9) Site Classification U—UNSUITABLE S—SUITABLE PS- rovisionaliy Suitable Recommendations/Comments: Described by IZ-- Titley Date SITE DIAGRAM DCHD(8-82)