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161 Shamrock Ln 1 ' :OG 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 and Disposal Rules (10 NCAC 10A .1934-.1968) Permit Number Name fti h C����. f:�R-rte Date s 3"573 Location �,1-� _rn i-'- 1't>v 01 r �.• �� _> . j R I L£ !S%^ <! i / /:C �Iri /�7 f�) .�_: I�/ t` /"�/• Z/ON c 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: /OvoG 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. /Z Cd 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 "�' `T�ct -S�-F-1 Ic ANr_ 04_, Certificate of Completion ��✓ Date 6 � *The signing of this certificate shall indicate that the system descri �d above has been installed in compliance with the standards set forth in the above regulation, but shall in NO way e taken as a guarantee that the system will function satisfactorily for any given period of time. i DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section R O. Box 665 Mocksville, N.C. 27028 SOIL/SITE EVALUATION Name_ ja'N� Jd�cA Date S� ?� Address 3 �Z Lot Size FACTORS AREA 1 AREA 2 AREA 3 AREA 4 1) Topography/Landscape Position S S S PS PS PS U U U U 2) Soil Texture (12-36 in.) Sandy, S, S S S Loamy, Clayey, (note 2:1 Clay) (0 PS PS PS U U U U 3) Soil Structure (12-36 in.) S S S S Clayey Soils /i PS PS PS �j U U U 4) Soil Depth (inches) S S S PS PS PS U U U U 5) Soil Drainage: InternalA S S S PS PS PS U U U U External S S S PS PS PS U U U U 6) Restrictive Horizons 7) Available Space S. S S p 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 Suitab Recommendations/Comments: Described by Title C��J-rz��...�� Date'y' . SITE DIAGRAM DCHD(6-82) . -/7 Fy APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT Davie County Health Department Environmental Health Section ` R O. Box 665 )C�&(DA Mocksville, N.C. 27028 CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.S6 2- Home Home Phone 1. Permit Requested By �/" �1D Business Phone --x-37 2. Address /OX-0 — ��� • C 3. Property Owner if Different than Above 2>62i-7 719" ?� • !�//'�- 1 �/a Address 4. Permit To: a) Instally 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 Y Business IndustryOther b) Number of people 6. a) If house or mobile home, state size of home and number of rooms. House Dimensions /2 X G D Bed Rooms -2 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 8. a) Type water supply: Public Private '� Community b) Has the water supply system been approved? Yes No 9. a) Property Dimensions >4 /,5-- dZ'& ^ 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. Dat6 Owner Signature OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL-LAWS Allow 5 days for processing Directions to property: � �e s _/ yo w `'IDU T fig/%74-7e— �j6G� �/�s5 /2'I 74- Com- DCHD(6-82)