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150 McClamrock Rd .....+..�; ....... .-.-<s. w, +t.u.,J"'-'i:i:^.-..,. .F.:i..v. .,.,.rya_ r r.:i ♦-.'.1.'Y:. ..�" .r ,+i'.. -.r r .., i..... - .r r r-.. .. ..... - ✓-r t. „ . .., - •r' DAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENTS PERMIT .AND CERTIFICATE OF COMPLETION "N&TE: 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 /�-� '�',`„�� ` :,��✓� ,`lam'� `j''` Date � L i,� i 11172 Location /� - ,�'” %/r,�J :,Z! Subdivision Name Lot No. Sec. or Block No. Lot Size - ��tZL House Mobile Home � Business __ Speculation No. Bedrooms _ No. Baths No. in Family _ Garbage Disposal YES p NO Specifications for System: �_` Auto Dish Washer YES i NO - �.. ,... t Auto Wash Machine YES NO F1 Type Water Supply __— `This permit Void if sewage system described below is not insta/lled-within 36 months from date of issue. I 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 �i L 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 ;,f 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 l CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED. Home Pho e 3 q-5&SC 1. Permit Requested By Co I V I r) yo Un f S J r. Businesshone (4 - 6 oo a 2. Address PD i.3rx .3'7 3 M n c.Ks v 1'11 e , /V C, 3. Property Owner if Different than Above Les f c to Address R+• -�Z M 6 cKs v 1*11 c , N (, 4. Permit To: a) Install_/ Alter Repair b) Privy Conventional--Z'Other Type Ground Absorption c) Sub-Division Sec. Lot No. r 5. System used to serve what type facility: House Mobile Homed Business �I6use /o f cr IndustryOther— (1 ther 3 3cdr6om s b) Number of people _ 6. a) If house or mobile home, state size of home and number of rooms. House Dimensions (e 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 2 showers washing machine . dishwasher 1 sinks f 8. a) Type water supply:Public )) Private Community b) Has the water supply system been approved? Yes No ` 9. a) Property Dimensions 450 " x 9� 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? 0Z 6Z,"- �e ` tt'-VLL LACr�, This is to certify that the information is correct to the best of my knowledge. Date 6 wner Signature OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS Allow 5 days for processing Directions to property: DCHD(6-82) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section R O. Box 665 Mocksville, N.C. 27028 SOIL/SITE EVALUATION Name S Date Address Lot Size S>(f FACTORS AREA 1 AREA 2 AREA 3 AREA 4 1) Topography/Landscape Position 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 1 #1 U U U 3) Soil Structure (12-36 in.) S S Clayey Soils PS PS U U 4) Soil Depth (inches) S S pS PS PS U U U 5) Soil Drainage: Internal S . S S S PS PS U 11 U U External S S S S PS PS PS PS U U U U 6) Restrictive Horizons Y, 7) Available Space ® 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 U—UNSUITABLE S—SUITABLE �PS—Provisionally Suitable Recommendations/Comments: Described by Title �� Date -Zli SITE DIAGRAM DCHD(6.82)