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4783 Hwy 801SDAVIE COUNTY HEALTH DEPARTMENT -.JMPROVEMENTS 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) ,1 Permit Number Name /�:-.�f- �� Date /r'� ,,ter -.f Vit.: %:; LocationF,�;_. Subdivision Name Lot No Sec. or Block No Lot Size Z House Mobile Home _�� Business _— Speculation No. Bedrooms — No. Baths�7 No. in Family Garbage Disposal YES p NO ff Specifications for S stem: 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. 4 ......�_ .. .. � syr...+ 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 C 1n( r `. Certificate of Completion ����r�'^P� Date ! �l. *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. • APPLICATION FOR SITE EVALUATION/ IMPROVEMENTS PERMIT Davie County Health Department Environmental Health Section R O. Box 665 Mocksville, N.C. 27028 CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED. m Home Phone 76, L ` 7 7(e 1. Permit Requested By /_�/Ap_�hQ7 GGU,�i� G� Business Phone26(o— OTOS 2. Address a r b -i/ a, ' K - -� 7 L _ ��� /�iy /U _.,.1 p3 3. Property Owner if Different than Above Address 4. Permit To: a) Install A 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 / IndustryOther b) Number of people f c/c6LG" 6. a) If house or mobile home, state size of home and number of rooms. House Dimensions 14 X lir Bed Rooms 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 l urinals garbage disposal lavatory 22f`F / showers �� / washing machine Z dishwasher "_15 a4p., sinks 8. a) Type water supply: Public Private Community b) Has the water supply system been approved? Yes No— 9. 9. a) Property Dimensions nrstio�Wm 20 o, X 3 7 < < l $ 4 (ke-r c 5 J 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? AL 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: Hwy ( kt 6 -Lo jjwy $UI TtsrN ric%hGo �_b Rwerolpw +h e w o:b e V)ac k DN e ) ()+ , (&", -3 r -J + 4+�, r iL v v l�wy �vl DCHD (6-82) DAVIE COUNTY HEALTH DEPARTMENT ' y 1 Environmental Health Section R 0. Box 665 Mocksville, N.C. 27028 SOIL/SITE EVALUATION Name-///i.�r'�i� :is�i�/� Date zvwgz� Address Lot Size`.3' FAr`TOP.q AREA 1 ARFA 9 ARFA 3 ARFA d 1) Topography/ Landscape Position 9) S S S S PS PS PS U U U ') Soil Texture (12-36 in.) Sandy, S S S S Loamy, Clayey, (note 2:1 Clay) j PS PS PS /� U U U 1) Soil Structure (12-36 in.) S S S S Clayey Soils<T PS PS PS U U U 1) Soil Depth (inches) S� S S S $% PS PS PS U U U U ) Soil Drainage: Internal S S S S PS PS PS U U U U External S S S S PS PS PS U U U i) Restrictive Horizons Available Space S S S PS PS PS PS U U U U 1) Other (Specify) S S S S PS PS PS PS U U U U Site Classification U—UNSUITABLE Recommendations/Comments: S—SUITABLE PS—Provisionally Suitable Described by Title Date SITE DIAGRAM ed1 by ............ jjj� . .. .. ........ .. ..... ...... ................ .. ... DCHD (6-82)