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309 McClamrock Rd DAVIE COUNTY HEALTH DEPARTMENT i ZVI_ f 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 ate Location Subdivision Name Lot No. Sec. or Block No. ' Lot Size C House A!'� Mobile Home _ Business Speculation No. Bedrooms ��� No. Baths ! _ No. in Family _ Garbage Disposal YES ❑ NO p! Specifications for,System: f Auto Dish Washer YES NO ❑ , ,-' Auto Wash Machine YES NO ❑ Type Water Supply *This permit Void if sewage system described below is not installed within 36 months from date of issue. f" r l r i Improvements permit by — % f *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 fir{ llvheCertificate of Completion � Date �n -*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. J , a�ARv� APPLICATION FOR SITE EVALUATION/IMPROVEMENTS P&WNE Davie County Health Department Environmental Health Section P. O. Box 665 d Mocksville, N.C. 27028 CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED. t Home Phone 1. Permit Requested By Th X Y e R6rV ,,8QU)fA?6 Business Phone '7!P 2. Address /YIC' 01,9mPock k 3. Property Owner if Different than Above Address 4. Permit To: a) Installer Alter Repair b) Privy Convention al_XZOther Type Ground Absorption c) Sub-Division Sec. Lot No. 5. System used to serve what type facility: HouseM bile Home Business Industry Other b) Number of people a 6. a) If house or mobile home, state size of home and number of rooms. House Dimensions !y/y '1r, Bed Rooms—Bath Rooms a. Den w/Closet b) If Business, Industry or Other, State: Number of persons served SIA What type business, etc. Estimate amount of waste daily (24 hours) 7. Number and type of water-using fixtures: commodes vp 3 urinals garbage disposal lavatory 4a� 3 showers washing machine dishwasher / sinks 1 8. a) Type water supply: Public Privately Community b) Has the water supply system been approved? Yes No 9. a) Property Dimensions 00A_P_ :S 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? NO What type? 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: S Wei �oc,Csv'UX l m cec `'� Ya DCHD(6.82) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section. P. O. 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 S PS PS U U 2) Soil Texture (12-36 in.) Sandy, S S S S Loamy, Clayey, (note 2:1 Clay) P PS PS U U U 3) Soil Structure (12-36 in.) S S S S Clayey Soilsr`) US PS US 1 N 4V .-- 4) Soil Depth (inches) S S S S P P PS PS U U U 5) Soil Drainage: Internal S __�y� S S S lPS/ PS PS U U U External S S S S PS PS U U 6) Restrictive Horizons 7) Available Space S S S S PS PS PS PS U U U U 8) Other (Specify) _ < % S S /rf qS '"'``PPS PS PS C� U U U U 9) Site Classification U—UNSUIT ABLEE PS—Provisionally Suitable Recommendations/Comments: �(� Described by `,lC � Title /t/ Date ���� SITE DIAGRAM 1 DCHD(6-82)