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1022 Salisbury Rd (2) DAVIE COUNTY HEALTH. ;DEPARTMENT• IMPROVEMENTSL PERMIT AND CERTIFICATE'OF, COMPLETION *NO.Tr: Issued in Compliance with G.S. of North Carolina ,Chapter 130 Article 13c Sewage Treatment and. Disposal Rules (10-NCAC 10A A934-.1968) P.ermit.-Number Name Date' ._ J - 2i1 M2 5055 Location " Z =(3 —SVJ� ;5 c, _1:D tt`o. �• \�,?1,/ 2 \ 1^R'' `J 1�� 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 J 0 ca 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. 7 60 ments permit by `Contact a representative of the Davie CoKH ealth Department for final inspection' of this system between. 8:30-. 9:30 A.M. or 1:00-1.:30. P.M. on day of; etion.` Telephone Nu 704-634-5985. Final Instal lation`Diagram: ® a System Ins Iled 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 a',a guarantee that the system will function satisfactorily for any given period of time.` ` APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT ,4��,�� Davie County Health Department CSI Environmental Health Section P. 0. Box 665 0 Mocksville, N.C. 27028 CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED. Home Phone = h2 1. Permit Requested By Business Phone 2. Address © o �-- 3. Property Owner if Different than Above Address 4. Permit To: a) Install v Alter Repair b) Privy Conventional Other Type Ground Absorption c) Sub-Division Sec. Lot No. 5. System used to serve what type facility: House Mobile Home :!! Business IndustryOther b) Number of people 6. a) If house or mobile home, state size of home and number of rooms. House Dimensions Bed Rooms—Bath Rooms 2 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 machiney dishwasher sinks 8. a) Type water supply: Public I-"-- Private Community — b) Has the water supply system been approved? Yes --No 9. a) Property Dimensions yC/r Y aao 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 Owner Signature OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS Allow 5 days for processing Directions to property: ' 61 Sa�� a4,4_ SO � �o� l4el-11 c� 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 ize FACTORS AR ARka AREA AREA(4 1) Topography/Landscape Position S PS P — U �-7J 2) Soil Texture (12-36 in.) Sandy, S Loamy, Clayey, (note 2:1 Clay) P U U 3) Soil Structure (12-36 in.) S Clayey Soils ('Q'P �P S U U 4) Soil Depth (inches) b SS U U AU 5) Soil Drainage: Internal S U" U U External S S p PS P U U U 6) Restrictive Horizons ------------- 7) -7) Available Space PS P � PSS U CEJ (lT 8) Other (Specify) S S S PS PS PS -- U U 9) Site Classification U—UNSUITABLE S SUInMd PS—Provisionally Suitable t Recommendations/Comments: v Described by Title Date -TZ a SITE DIAGRAM QZ UCHD(6-82)