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1695 Yadkin Valley Rd _y,,.M,,: ti:W {,;.L..`'•v<<—::..z:s.y-..5:''Yr-.'w,�:^u.r�a�..�...:j. _voi.•' �n,.,x,:✓r..v _ .a:�C, .. .... . .. ,... _ ,... . .{� 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 arjd Disposal Rules (10 NCAC 10A .1934-.1968); Permit.. Number Names `�\U \� C� � �. Date NO Location VX-V 1 _ � _ i Sfi. t, - S e\ '.fie � *,� ( .J �� •\� �'f'\ �= `+ `?-. .�c�., �,� �.._ ,r- U•, (! t.:. Subdivision Name Lot No, Sec. or Blick No. Lot Size `i� " -'~ House Mobile Home Business Speculation No. Bedrooms No. Baths a-��- No. in Family Garbage Disposal YES ] NO Specifications for System. Auto Dish Washer YES ❑ NO p,- Auto Wash Machine YES Q` ,NO ❑ ,+ Vs Type Water. Supply *This permit Void if sewage system described below is not installed within 36 months from date of issue. 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 4 i r- 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 as a guarantee that the system will function satisfactorily for any given period of time. ri APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT Davie County Health Department + . Environmental Health Section P. O. Box 665 " Mocksville, N.C. 27028 CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED. L Home Phone l r _ O faop 1. Permit Requested By ABusiness Phone 2. Address l � e ,2 7 0 0 6 3. Property Owner if Different than Above 66 Address __ �& 96 K ? / /2 G )d d� 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 Homey Business IndustryOther b) Number of people 6. ay If house or mobile home, state size of home and number of rooms. House Dimensions / 010 f f Bed Rooms s Bath RoomDen 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 a urinals garbage disposal lavatory showers washing machine dishwasher sinks // 8. a) Type water supply: Public Private k< Community b) Has the water supply system been approved? Yes No_C 9. a) Property Dimensions b) Land area designated to building site c) Sewage Disposal Contractor 10. Do you anticipate any additigns or pan_ sons of the facility this sewage system is intended to serve? What type? Q This is to certify that the information is correct to the be of m knowledge. 0 C) - �q — AVW Date Owner Signature OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS Allow 5 days for processing Directions to property: ,� n ow. l . � 2 DCHD(6.62) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section, P. O. Box 665 Mocksville, N.C. 27028 SOIL/SITE EVALUATION Name Q C\\ Date I o," - Address •s t> t1ZAN CZ- Lot Size ns k) FACTORS AREA 1 AREA 2 AREA 3 AREA 4 1) Topography/Landscape Position S S <:::N <ZIMD) <�) <k U U U 2) Soil Texture (12-36 in.) Sandy, � � Loamy a e , (note 2:1 Clay) PS (k) ` 6 U U <ku 3) Soil Structure (12-36 in.) Clayey Soils PS U U U 4) Soil Depth (inches) CD S S S PS P U U U U 5) Soil Drainage: Internal - pS External S U U U U 6) Restrictive Horizons 7) Available Space U U 8) Other (Specify) S S S S PS PS PS PS 9) Site Classification S QP's— U—UNSUITABLE SS SUITA E PS—Provisionally Suitable Recommendations/Comments: - 1 Vb Described bye' -� Title �c �� � Date SITE DIAGRAM F . L DCHD(6-82) Davie County Health Department BVS�$� Environmental Health Section Phone: (336) - 753 - 6780 Oct P.O. Box 848 210 Hospital Street Courier # : 09-40-06 Mocksville, NC 27028 ON-SITE WASTEWATER CERTILFICATION (Check One) Replacement Remodeling Reconnection Fax: (336) - 753-1680 Name: (a .Q ( 54(/v e- & )�C- Phone Number 33(� gl 7'" yI % (Home) Mailing Address: Z - ,` Sof _ (Work) ANG 27coco Email Address:�jl� ,-s- _ y44e% .1 Detailed Directions To Site: ,Qedj6, .t JU Y4dAk V..8' y RJ &,-,I A4 C,c !/Z' ow'e 6? t 0" Property Address: / v Please Fill In The Following Information About The EXISTING Facility: Name System Installed Under: Type Of Facility: Date System Installed (Month/Date/Year): Ce r`t Number Of Bedrooms: _Number Of People: Is The Facility Currently Vacant? Yes No If Yes, For How Long? Any Known Problems? Yes No If Yes, Explain: Please Fill In The Following Information About The NEW Facility: Type Of Facility: Sun/'oo/,► ©n 6, sj,l.g kQv f�{ Number Of Bedrooms: Number of People. i Pool Size: Garage Size: Other: Requested By: Date Requested: %OI14105--' (Signature) �1 For Environmental Health Office Use Only Approved Disapproved Environmental Health Specialist *The signing of this form by &EnvironAental Health Staff is in no way intended, nor should be taken as a guarantee (extended or limited) that the on-site wastewater system will function properly for any given period of time. Payment: Cash Check Money Order # Paid By: Account #: Amount:$ Received By: Invoice #: