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6538 Hwy 801S (2) -�A! . !_ DAVIE COUNTY HEALTH DEPARTMENT --eaq-6 r j� 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 Name r /A , r Date I. Location Subdivision Name Lot No. Sec. or Block No. Lot Size _ House Mobile Home Business Speculation No. Bedrooms ��_ No. Baths _�_ No. in Family Garbage Disposal YES ❑ NO [] Specifications for System: Auto Dish Washer YES ❑ NO C] /%> i ,�" Auto Wash Machine YES NO ❑ �,, Type Water Supply `This permit Void if sewage system descnbed below is not installed within 36 months from date of issue. 1 X1.7 'Improvements permit by i `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 r` -------------- /7 /,->� Certificate of Completion W, . /� date' 'The signing of this certificate shall indicate that the system described above has been installed in compliant .m - the standards set forth in the above regulation, but shall in NO way be taken as a guarantee that the systew- ill function satisfactorily for any given period of time. T ' ! APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT �¢C �5 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 -Z Z 1. Permit Req4ested By Business Phone 2. Address - / 3. Property Owner if Different than Above Address 4. Permit To: a) Installer Alter Repair b) Privy Conventional Other Type Ground Absorption c) Sub-Division Milid ,"41'l°t Sec. Lot No. 5. System used to serve what type facility: House Mobile Home--ZBusiness IndustryOther b) Number of people 6. a) If house or mobile home, state size of home and number of rooms. House Dimensions 2 x '7 ' 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) 7. Number and type of water-using fixtures: commodes urinals garbage disposal lavatory . ` t showers 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 t crc P� b) Laid area designated to building site C) Sewage'Disposal Contractor 041 r 10. -Do you anticipate any additions or expansions of the facility this sewage system is intended to serve? m What type? This is to certify that the information is correct to the best of my knowledge. /�- 3d Y5 Date Owner Signature OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS Allow 5 days for processing Directions to property: (0O 1 e, rpt . vt.,�� dvz � ����� �� ✓� � �� `��Z'7t17 iz� 46 i < 0 h(n�//�//f/� !�crl � - �/Z C�yet v G � fe>I k'o n C1rG_ 'hv)' vr-r a � L4-' , t r ' DCHD(6-82) Ago f� l r : - DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section R O. Box 665 Mocksville, N.C. 27028 SOIL/SITE EVALUATION Name PUSS Date �//Z;; W Address Lot Size -40. �D6 FACTORS AREA 1 AREA 2 AREA 3 AREA 4 1) Topography/Landscape Position S S S S 61 PS 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 U. 3) Soil Structure (12-36 in.) S S S S Clayey Soils 0 PS PS PS U U U U 4) Soil Depth (inches) S S S S 40, PS PS PS U U U U 5) Soil Drainage: Internal S S S S /p� PS PS PS �j U U U External �S S S S c� PS PS PS U U U - U 6) Restrictive Horizons ��- 7) Available Space S S S S PS PS PS U U U U 8) Other (Specify) S S S S PS PS PS PS U U U . U 9) Site Classification F U—UNSUITABLE S—SUITABLE �tP�roisiio�nallySuitable Recommendations/Comments: Described by ! Title Date lam` SITE DIAGRAM DCHD(6-82) 1