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1171 Yadkin Valley Rd (2) . ,. a A:-. .. __ •- -. __ _ ...- -- _ _._Il �_• ._�� �.�'nM1V./"�-- rs -. a �1 po' ` 1 DAVIE COUNTY HEALTH DEPARTMENT f`� IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETIONS, *NOTE:^ Issued in,Compliance v✓ith.GS: of North Carolina Chapter 130 Article 13c _ Sewage Tre'atment'and Disposal Rules (10 NCAC 10A .1934-.1968) Permit Ntbmb ' Name Date =6�'il $7 � -`.4613 Location* ,c�.�`r � � .s�:�.=tiS�� ,�, � c}� � , .�•9 dr^. 7�X�, � �".`cir�..ha. Cj.sS1,M��\"'� Subdivision Name Lot No. ii H Sec.•or Block No. Lot,.Size , Q,6: House.• V Mobile Home ' ` Business Speculation No:Bedrooms �� �` No. Baths; �~ No. � III:- if t o. in Family— — ;� II:- Garbage Disposal 'YES 0 ' NO•:y� Specificatlioins for Systern � Auto Dish Washer YES NO Auto Wash,Machine YES �j NO ,� I . . ,. ; Type Water Supply, *This:permit-Void if sewage system-described below is not installed within 36 months from date of issue. 14 If - .. •� �� I •I II � tel. - . - �!� Im vements permit"bye *Contact a representative of the DavieCounty Health. Department for final inspection of this system between 8:30- 9:30,,A.M.:or 1 G)e.30;jP.M. on. day of mpletion. Telephone Number: 704.1!634-5985. „ !Final'Installation-D' r System Installed by ' .. I',. Y—......_--rte•,..-.-.�..._.a.� ,�� ,. 4 'I ' . Certificate of Completion,. f ' Date Q � W -f II:, '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 w•ilhfunction satisfactorily for,any given period of time. 1 APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT Davie County Health Department Environmental Health Section P. O. Box 665 RECEIVED DEC 2 3 1986 Mocksville, N.C. 27028 CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED. Home Phone d 1. Permit Requested By RA11 r Business Phone g d 2. Address o C C T 3. Property Owner if Different than Above 'Z )a Al of JOL-110-R�I� /`!n13� Address t� t a7U0 4. Permit To: a) Install V Alter Repair b) Privy Conventional Other Type Ground Absorption c) Sub-Division NO Sec. Lot No. 5. System used to serve.what type facility: House ✓ Mobile Home Business Industry Other b) Number of people I 6. a) If house or mobile home, state size of home and number of rooms. House Dimensions '36 Bed Rooms—Bath Rooms:—Den w/Closet_�� b) If Business, Industry or Other, State: Number of persons served ILIO 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 f 8. a) Type water supply: Public Private Community b) Has the water supply system been approved? Yes1'No 9. a) Property Dimensions add X a o b 'Fess'.q Aj ."4VZ At –T46.41-1 b) Land area designated to building �/l1site 60 P. &� O Ck hV �4 crls C) Sewage Disposal Contractor /Z9 27L-a k 7,L J2111m)1 10. Do you anticipate any additions or expansions of the facility this sewage system is intended'to serve? Al c What type? This is to certify that the information is correct to the best of my knowledge. RG 2& 6_e� 1 9 Date V Owner Signatur OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS Allow 5 days for processing Directions to property: ott- Allay Nupc,1 �o�d ylqdyilj �n,��fi Lr A�`Al' 7'OR �o u S ° - e 4- :., AGN lnb,24n/ • DCHD(6-82) . DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Box 665 Mocksville, N.C. 27028 SOIL/SITE EVALUATION Named-� \+c.� -Q� C� Date Address /)� �'� � `-` � Lot Size J FACTORS AREA 1 AREA 2 AREA 3 AREA 4 1) Topography/Landscape Position ,S S & © P PS' U U U 2) Soil Texture (12-36 in.) Sandy, S S S S Loamy, Clayey, (note 2:1 Clay) PS PS Cud QU U 3) Soil Structure (12-36 in.) S S S Clayey Soils � � '�S U 4) Soil Depth (inches) S S S PS � S) 5) Soil Drainage: Internal S S S PSPS Ca) External S S S PS US U 6) Restrictive Horizons 7) Available Space S PS PS CiD U U U U 8) Other (Specify) S . S S S PS PS PS PS Uc U U . U 9) Site Classification J U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable Recommendations/Comments: Described by ����� Title Date SITE DIAGRAM DCHD(6-82) _