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2289 Hwy 601S 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 .19�3/4-.1968) ( i Permit Number Name S!z� t 1 c �_ <�- Date / ' �0 ` 4 i�.n r Location -rl SO v i!� n L.i"7" /r C/12Df 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 L'J Specifications for System: /000 Auto Dish Washer YES � NO ❑ P y Auto Wash Machine YES .E] NO ❑ x 3 rX Type Water Supply *This permit Void if sewage system described below is not installed within 36 months from date of issue. f 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 ?PAAIQ (9ifI IG 3 LD Certificate of Completion Date.41 '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. ''�' ►-';� " DAVIE COUNTY HEALTH DEPARTMENT r- 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 1 OA .1934-.1968)- Permit Number NameC r v 1� c a«� c� j(� t f Date �'��' 3524 Location �--, / Sa v i!� dr. �.iT / C`_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 [ll" stem:Specifications for S Auto Dish Washer YES [� NO' ❑ p f `` Py Oba <:, ���k �4tL r Auto Wash Machine YES ❑ NO ❑ 3�/� X 3 x Type Water SupplyC"� _— - ' gif -,I "? *This permit Void if sewage system described below is not installed within 36 months from date of issue. a 5 Improvements permit by —i 4 �----'' *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 �c- f 3 Certficate of Comp etion � 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. DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section R 0. Box 665 Mocksville, N.C. 27028 SOIL/SITE EVALUATION Name G �l t.c,q-fLt7 Date Address Lot Size FACTORS. AREA 1 AREA 2 AREA 3 AREA 4 1) Topography/Landscape PositionS Is 'PS S PS PS U U U U 2) Soil Texture (12-36 in.) Sandy, S S S S Loamy, Clayey, (note 2:1 Clay) ® PS PS U U U 3) Soil Structure (12-36 in.) S S S Clayey Soils S lP, PS PS lT U U 4) Soil Depth (inches) S S PS PS PS PS U U U_ U 5) Soil Drainage: Internal S S S S PS PS PS PS U U U U External S S S S PS PS PS PS U U U U 6) Restrictive Horizons 7) Available Space S S. S S PS 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 Suitable Recommendations/Comments: Described by Title Date E17/ SITE DIAGRAM DCHD(6-82) APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT Davie County Health Department Environmental Health Section P. O. Box 665 Mocksviile, N.C. 27028 i. , CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED. Home Phone a g o a 040 1. Permit RequestBy Business Phone 634-"'3591 2. Address e — 1 0 QR 3. Property Owner if Different than Above JC�4m a above. Address 4. Permit To:a),Install Alter Repair V b) Privy Conventional Other Type Ground Absorption 4c) Sub-Division Sec Lot No 5. System used to serve what type facility: House Mobile Home Business IndustryOther b) Number of people 4- 6. 6. a) If house or mobile home,state size o1 homy and number f rooms. House Dimensions_ 2 X X0 C 5 Poomsi, Bed Rooms—Bath Rooms—Den w/Closet_ b) 0 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 1 dishwasher sinks 1 8. a)Type water supply. Public Private Community �p b) Has the water supply system been proved?Yes_ L No 9. a) Property Dimensions 12a9-99/)(1Q0.08 X a Q/. 6a b) Land area designated to building site •baa cacr s V c) Sewage Disposal Contractor 10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve? _LY0 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:' o � from Moc ksvif le 1-o i tlte(`se cf'on TaKe Hi�1�wgy h � soy of H;c Wci s 601 qA $01 (Gpecjsy Corner. �0 4bo�t - rni�e ��r et` Soub on y6�1 To mobile kom , eqpk on left. The lot i's kcgted Olt back ofa r k o n the r t S1, of c v% Vemp P � y DCHD 0-84