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201 Major Rd (2) 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 d Disposal Rules (10 NCAC 10A .1934-.1968) Permit Number.- Name �%' ,. a Date N� 4005 Location Subdivision Name Lot No. Sec. or Block No. Lot SizeHouse Mobile Home Business Speculation No. Bedrooms `� No. Baths _ No. in Family _ Garbage Disposal YES ;O NO Specifications for S ste Auto Dish Washer YESNO fl l'�ef eoo4s�a� �� Auto Wash Machine YES NO C] u / . Type Water Supply. l'�% �/�� __ � ��/� ot_224� *This permit Void if sewage system described below is not installed within .36 months from date of issue. eoV c 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 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. --=m-" 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 Treatments1a,Disposal Rules (10 NCAC 10A .1934-.1968) _ L Permit Number Name 11�i>� ,?� Date �����5 � iJ Location J Subdivision Name Lot No. Sec. or Block No. Lot Size f House `'—� Mobile Home _ Business Speculation No. Bedrooms No. Baths No. in Family Garbage Disposal YES ❑ NO Specifications for.System: Auto Dish Washer YES NO ❑ �Gl, , � l ,,. Auto Wash Machine YES g NO ❑ Q � Type Water Supply ��/,!�� __ ����� i ./� 161f- *This permit Void if sewage system described below is not installed within 36 months from date of issue. 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 Installedby �4. 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 IMPROVEMENTS PERMIT AND, CERTIFICATE OF COMPLETION � 1 *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 / Date `` / /^' 3 4 0;0 5 Location ,%'r — it/y, Subdivision Name Lot No. Sec. or Block No. Lot Sizes e House ~ Mobile Home _ Business Speculation No. Bedrooms - '� No. Baths _ No. in Family Garbage Disposal YES ❑ NO,p'-' Specifications for. System: Auto Dish Washer YES Ep NO r Auto Wash Machine YES p NO ❑ ` Type Water Supply *This permit Void if sewage system described below is not installed within 36 months from date of issue. l• 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 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. • APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT Davie County Health Department Environmental Health Section R O. Box 665 Mocksville, N.C. 27028 CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN IS UED. S 77 02 fE-��y9 Home �hone � 1. Permit Requested By ©�� y �• ��2�E y Business Phone 2. Address/ZT, 3 leo X S/3 , lLloc/4�Sy/LLQ 3. Property Owner if Different than Above AZA51-1� x• Address 12T, �-, ff r�d��✓L� /✓• �7ooG 4. Permit To: a) lnstall�ZAlter Repair b) Privy Conventional Other Type Ground Absorption c) Sub-Division Sec. Lot No. S. System used to serve what type facility: House-4t:--fMobile Home Business IndustryOther b) Number of people Ll 6. a) If house or mobile home, state size of home and number of rooms. House Dimensions I7ao Bed Rooms_3 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 showers washing machine dishwasher sinks 3 8. a) Type water supply: Public Private Community b) Has the water supply s stem been ap roved? Yes No ---- 9. a) Property Dimensions /C r-$ 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 UOwner Signature OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS Allow 5 days for processing Directions to property: r✓ /� �/ �i9�f' I 1 . r I k i E DCHD(6-82) 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 4 no 2. 1 am not the owner of the above described property, however, I certify that I have consent fromInAToi2 964uC64/7?P , 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. yes 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 for a.ground absorption sewage treatment and disposal system. vti r � DATE SIGNATURE 4. ,I hereby authorize the Davie County Health Department to release site evaluation results from the above'described property to the following: — Owner only — Owners designated representative Anyone requesting results _.LOnly those listed below 5ille Alr- DATE SIGNATURE DCHD(11/84) • DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section R 0. Box 665 Mocksville, N.C. 27028 SOIL/SITE EVALUATION Name 4e(Z — Date _2�z,/�d "f Address Lot Size_T�� FACTORS AREA 1 AREA 2 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 S S Loamy, Clayey, (note 2:1 Clay) PS PS PS 0 U U 3) Soil Structure (12-36 in.) S S S S Clayey Soils PS PS PS PS U U 4) Soil Depth (inches) S S S S PS � PS PS U U 5) Soil Drainage: Internal S S S S PS PS PS U U U External S S S S PS PS U U 6) Restrictive Horizons 7) Available Space co S S PS 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 fir r U—UNSUI LE S—SUITABLE PS—Provisionally Suitable Recommendations/Comments: Described by Title Date SITE DIAGRAM -J10` OSv DCHD(6-82) . _ .. DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. 0. Box 665 Mocksville, N.C. 27028 SOIL/SITE EVALUATION Name Date Address Lot Size FACTORS AREA 1 AREA 2 AREA 3 AREA 4 1) Topography/Landscape Position S S SS PS U U U U 2) Soil Texture (12-36 in.) Sandy, S S S S Loamy, Clayey, (note 2:1 Clay) P PS PS PS U 3) Soil Structure (12-36 in.) S S S S Clayey Soils PS PS PS U 4) Soil Depth (inches) S S S S PS PS PS PS C �1–� --Cs> U 5) Soil Drainage: Internal S S S S PS PS U External S S S S PS PS PS PS U U U U 6) Restrictive Horizons 7) Available Space S S PSPS PS U U U U 8) Other (Specify) S S S S PS PS PS PS U / U U U 9) Site Classification J (� U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable Recommendations/Comments: Described by Title Date SITE DIAGRAM 2 E r f DCHD(6-82)