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158 Sparks Rd 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 L�4 \ � ;` �� 5-1 Date 1 NO_ ; U(, Location ``.\ Subdivision I�Jame�"c.�, _. Lot No. Sec. or Block N .Lot Size �� �' House Mobile Home —L Business SpecuNtion " No. Bedrooms No. Baths � No. in Family�— Garbage Disposal YES fl NO .0 Specifications for System: Auto Dish Washer YES d 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. Q) Y �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 (MVV +' Certificate of Completion 4 N 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. w T APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT Davie County Health Department Environmental Health Section AUG 0-7 P. O. Box 665 REQ Mocksville, N.C. 27028 CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED. Home Phone 9 cls_ 5940 3 1. Permit Requested By LAbY5 L. HA GS Business Phone 91?F S 4t73 2. Address 2- 1 (, R k (oO -A ,4d--V-Q, N__0_ Pi .2-7.06 I 3. Property Owner if Different than Above Address 4. Permit To: a) Install ✓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 Homed Business Industry Other b) Number of people �- 6. ay If house or mobile home, state size of home and number of rooms. House Dimensions'I L4 X -)of Bed Rooms_Bath Rooms Z- 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 Z- urinals - _ garbage disposal lavatory _>- showers Z washing machine dishwasher _d- sinks 3 8. a) Type water supply: Public Private Community b) Has the water supply system been approved? Yes No 9. a) Property Dimensions Zoo' X 2 b) Land area designated to building site c) Sewage Disposal Contractor FP-A0 K. TP-AnJSoy 10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve? A,10 What type? T This its to certify that the information is correct to the best of my knowledge. 7 - &9 Aze&y �f - X4��2 Date Owner Signature OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS Allow 5 days for processing Directions to property: 901 /U0I2-VV\ tO 2-N0 t1 Q* W(-C- *o YA)b(Z-W V A ft%� 1( - 1 GO OAJ SAA�r✓ VoAb 1455 ((l2;V&?_ 'ALS). �o A) jr'j l��, 3 s�d� t cx lL ��5�� 1-1�w 'bPC**oZ"aa n Aom er4 � �c� '�C� `( 4��) b� e)( GL /h /X e � /-S DCHD(6-82) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section. P. O. Box 665 Mocksville, N.C. 27028 1 SOIL/SITE EVALUATION Name Date g �� Address Lot Size 6, 3 FACTORS A �EA1 ARA 2 AR 3 AREA 1) Topography/Landscape Position S P P 40 U U U 2) Soil Texture (12-36 in.) Sandy, S Loamy, Clayey, (note 2:1 Clay) d� PS (t) U U U 3) Soil Structure (12-36 in.) Clayey Soils A) U U U U 4) Soil Depth (inches) � � PS U U U 5) Soil Drainage: Internal � � S\ S� U U U U External S G 3 PSP U U U U 6) Restrictive Horizons —� 7) Available Space PS PS PS PS U U U U 8) Other (Specify) S S S S PS PS PS PS U U- 9) Site Classification -5 U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable Recommendations/Comments: , 'r-- Described byTitle -- Date _ SITE DIAGRAM DCHD(6-82)