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183 Meadowlark Lane Lot 17, r,+-r-�,.,,.--�.,...- c;r -�wy-*•�re- ry ,yam V '4 `i�,/ '�)�'TY`� 9t^a ca►3 q•-.,.. ,.-"�Vvru:"c,r,,, DAVIE COUNTY HEALTH DEPARTMENT Name:- 6 i 0' Environmental Health Section J PROPERTY INFORMATION P.O. Box 848 `' Directions to Property: le 1 /V R �� Mocksville, NC 27028 Subdivision Name:. W14 ia�6 Lor 1' �dw IF�Section: Lot: Phone #: 336-751-8760 /7 W�-e�% � °. JK *#446,,,..16AUTHORIZATION FOR VTV,' WASTEWATER Tax Office PINAM[t 1 _ �►04 0 19 �' /SYSTEM CONSTRUCTION AUTHORIZATION NO: 00 .r1 iRoad N3�a r.�Giy �G r ,r� ZiP: 'l **NOTE** This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior to issuance of any. Building Permits. This Form/Authorization Number should be presented to the Davie County Building Inspections Office when applying for Building Permits. (In compliance with Article'] 1 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) **NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION 7 r" ♦ IS VALID FOR A PERIOD OF FIVE YEARS. ENVIRONMENTAL HEALTH SPECIALIST - .DQTE ISSUED' RESIDENTIAL SPECIFICATION: BUII DING.TYPE # BEDROOMS, #BATHS) Ii OCCUPANTS GARBAGE DISPOSAL: Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No 3(,0 4PPfy- .290 Ty -ft-P$4- LOT SIZE L�,CTYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD) NEW SITE REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE _GAL. PUMP TANK _%GAL. TRENCH WIDTHOCK DEPTH LINEAR FT. OTHER �/% 11 !/ —J- o .0 ra l Ud dlJ r/1 nj H d 'i U / -/. m t � REQUIRED SITE MODIFICATIONS/CONDITIONS: 1 ill (1610 A • lQ h"A rct C. i of "'f d C Q J(40r' ROVEMENT PERMIT LAYOUT WOT I pia•, r iFC:13 wAnLiinr 64, Fiaaf 0r4,iA' " I%4A5� . be ;0:540 11-od 1 koof Lowe✓ tka••� %ok-�,`� Sr./oy��C�/pwc� Qvi 7,4 le Loc vflo�f' a s�r/oe-f �(u�e✓$-1C,64 Ore, IkOL'Ad 'jtgv"t r% -e V if o v+"r' o1 Iv *t - a !t d ittautr �u/atlle1 'to Kpp-•J pe4p4d y'1, 84 C) rut.. C3e.'f "of 9ev4 C I01 -CA* -V air4 et*e : c , 6 1 a or ea FOR FINAL INSPECTION OF THIS SYSTEM PLEASE CALL BETWEEN 8:30 - 9:30 A.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (336) 751-8760. OPERATION PERMIT - SYSTEM INSTALLED BY: AUTHORIZATIONNO. OPERATION PERMIT BY: DATE: "THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE WITH ARTICLE 11 OF G.S. CHAPTER 130A, SECTION .1900 "SEWAGE TREATMENT AND DISPOSAL SYSTEMS", BUT SHALL IN NO WAY BE TAKEN AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME. D= 02102 (Revised) Permit, ee's' "' DAVIE COUNTY HEALTH DEPARTMENT Name: fI` �r' .1, 4)IN C 1• � Environmental Health Section PROPERTY INFORMATION - � P.O. Box 848 k Drrections to property:%'�,? f!) P.O. NC 27028 Subdivision Name: Phone #: 336-751-8760 0 _6, �w�> l(;_iG(• fd =r'/' Section: Lot: q iAUTHORIZATION FOR C WASTEWATER d"i�'�"' �`%!✓; r: f% !> r - x t , �1 d�F tl ` Tax Office PIN:# —r l , ''� 1 SYSTEM CONSTRUCTION i f AUTHORIZATION NO: 002851' A Road Name: Zip: . **NOTE** This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior to issuance of any Building Permits. This Form/Authorization Number should be presented to the Davie County Building Inspections Office when applying for Building Permits. (In compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION f = .�•' �!i'�,./� Y.E. / (1. j.*. -'1 ` e IS VALID FOR A PERIOD OF FIVE YEARS. ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED RESIDENTIAL SPECIFICATION: BUILDING TYPE / # BEDROOMS __�2/ # BATHS # OCCUPANTS h' GARBAGE DISPOSAL: Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE It PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No W.F i I 3tr0 u/gip v LOT SIZE < <TYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD) NEW SITE REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK % GAL. TRENCH WIDTH ROCK DEPTH —,--"LINEAR FT. ./ OTHER -141 G y r41/ 0 1 .''1 �t H Gl j C t J r• f yr a REQUIRED SITE MODIFICATIONS/CONDITIONS: e_4 1 % i0' j� G 14 e a y 'A r n.C7 t=}t -1 b f a i 1 G Ir Nky! r G CIO , PERMIT LAYOUT 11'Al X0.5 Lr , • 11 1 C,,i FOR FINAL INSPECTION OF THIS SYSTEM PLEASE CALL BETWEEN 8:30 - 9:30 A.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (336) 751-8760. 9 OPERATION PERMIT i SYSTEM INSTALLED BY: AUTHORIZATION NO. OPERATION PERMIT BY: DATE: "THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE WITH ARTICLE 11 OF G.S. CHAPTER 130A, SECTION .1900 "SEWAGE TREATMENT AND DISPOSAL SYSTEMS", BUT SHALL IN NO WAY BE TAKEN AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME. DCHD02102 (Revised) /1961,0 �5_0S�( _IN /• 1• I i- &(-1-71 _q 4c,.. G(((uuu�))�\� 1 (u)� t3' iVCi' al•`� V%G # A (h u'y� E 1 rA 1 u 1l fCs� OG'� l lI p I U r.A- —a 5 I c f- 04 Cr , F 0 a1 ej I'U f,V 1IG✓1 . Of C, %A .511Gt-,Lrj 51vW- r-. ejtA I f ULl CLA-1 Gi� F�VUU HC/ tl f QV �l1G FOR FINAL INSPECTION OF THIS SYSTEM PLEASE CALL BETWEEN 8:30 - 9:30 A.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (336) 751-8760. 9 OPERATION PERMIT i SYSTEM INSTALLED BY: AUTHORIZATION NO. OPERATION PERMIT BY: DATE: "THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE WITH ARTICLE 11 OF G.S. CHAPTER 130A, SECTION .1900 "SEWAGE TREATMENT AND DISPOSAL SYSTEMS", BUT SHALL IN NO WAY BE TAKEN AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME. DCHD02102 (Revised) /1961,0 �5_0S�( _IN /• 1• I i- &(-1-71 LE C2 J J 11 LE M v e Frq I IC I ;i. � k 7U I 0( i t -mo SAM, 9 DAVIE'COUNTY HEALTH DEPARTMENT 7 -IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION Z�?� 'NOTE Issued ihi Compliance With Article II of G.S. Chapter 130a ' Sanitay Se wa a Systems: �Lf"/4l'„�ed�r�+ �'� �. Peti'mit Number Name Name ,%A r t.=2_''%/d?Date + NG/ 7 1 f Location �v f.�li' t ? . _l �'., ✓��, �% �t` �' Pfe Gr/i% �'G !c! �� q. Subdivision Name 9Lot No. Sec. or Block No. �• Lot Size_ _ House �_` Mobile Home —_ Business -- Industry No. Bedrooms —.No. Baths — No. in Family* Public Assembly Other Garbage Disposal. YES NO p; Specifications for System:y�j Auto Dish Washer YES NO ❑” /,oe9,� Auto Wash Ma^hine YES NO. p /l/t/11 �� � / la✓� Type Water Supply - --- ;a 'This per;nit Void if sewage system described below is not installed within 5 years from date of issue. This permit is subject to revocation if site plans�or the intended use change ATTENTION: y YOUR SEPTIC SYSTEM CONTRACTOR MUST SEE THIS PERMIT/LAYOUT BEFORE INSTALLING THIS SYSTEM. rt o ~ 1 Improvements permit by *QQ;�ontact a representative�of the vie Country Health Department for final Inspection of this system between 8:30-9:30 A.M., 1-1:'00-1:30 P.M. or 4:305`.00 P� n day of'completion. Telephone Number: 704-634-598&. g9146 i Ole Final Installation'Diagr m: Syst nstalled by ,�_ — �;ro 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. h f. APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT Davie County Health Department Environmental Health Section _ P. O. Box 665 l Mocksville, NC 27028 1. Application/Permit Requested By _A,1// Mailing Address 1-17 Home Phone 9%Q^�3Cd�C, Business Phone 2. Name on Permit if Different than Above J1 1?/q 3. Application for: ❑ General Evaluation WSeptic Tank Installation Permit 4. System to Serve: Ouse ❑ Mobile Home ❑ Place of Public Assembly ❑ Business ❑ Industry ❑ Other ❑ Unknown 5. If house, mobile home: Subdivision � C owc� Section Lot # No. of People No. of Bedroor No. of Bathroo Dwelling Dime 6. If business, industry, place of public assembly, other: Specify type No. of People Served No. of Commodes No. of Lavatories No. of Sinks No. of Urinals No. of Water Coolers No. of Showers Water Usage Figures _ 7. Type of water supply: �/j�Public �j�il? e1� Private 8. Property Dimensions AD �/ 40 Sewage Disposal Contractor 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? If yes, what type? ❑ Yes asement/Plumbing ❑ Basement/No Plumbing ❑ Washing Machine ❑ Dishwasher ❑ Garbage Disposal ❑ Community 'NOTE: Improvements Permits shall be valid for a period of 5 years from date issued. Improvements Permits are subject to revocation, if site plans or the intended use change. Effective October 1, 1989. Directions to Property: This is to certify that the information provided is correct to the best of my incurred from thi ap I' tion. DATE and I undgrstand I am responsjb)e for all charges TURE CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY MUST CHECK ONE: ❑ 1. 1 OWN the property. ❑ 2. 1 DO NOT OWN the property. If you checked Box #2, the rest of this form MUST be completed by the owner or a person authorized by the owner: I hereby give consent to the authorized representative of the Davie County Health Department to enter upon above described property located in Davie County and owned by to conduct all testing procedures as necessary to determine said site's suitability for a ground absorption sewage treatment and disposal system. DATE SIGNATURE DCHD (1193) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation NAME ,/J/ /N DATE EVALUATED t e4D/oS ADDRESS �� PROPERTY SIZE _7�/ c PROPOSED FACIILTY//l f C� LOCATION OF SITEC,11,6% Water Supply: On -Site Well Community Public LI -1, Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3 4 Landscape position U A- L L Slope % HORIZON I DEPTH ' Texture group Consistence Structure Mineralogy HORIZON II DEPTH T C�- Texture groupC C Consistence Structure it Mineralogy HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION TT LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: LONG-TERM ACCEPTANCE RA REMARKS:!n. %G'/1 ;N/ DCHD(01-901 EVALUATED BY: ' ,a // OTHER(S) PRESENT:��%Ji/ �, LEGEND QUX� X /� Landscape Position R -Ridge S -Shoulder L -Linear slope FS -Foot slope N -Nose slope CC -Concave slope CV -Convex slope T -Terrace FP -Flood plain H -Head slope Texture S -Sand LS -Loamy sand SL -Sandy loam L -Loam SI -Silt SICL-Silty ':lay loam SIL -Silty loam CL -Clay loam SCL-Sandy clay loam SC -Sandy clay SIC -Silty clay C -Clay CONSISTENCE Moist VFR- V, ---y friable FR -Friable FI -Firm VFI-Very firm EFI-Extremely firm Wet NS -Non sticky SS -Slightly sticky S -Sticky VS -Very Sticky NP -Non plastic SP -Slightly plastic P -Plastic VP -Very plastic Structure 3C --Single grain M -Massive CR -Crumb GR -Granular ABK-Angular blocky SBK-Subangular blocky PL -Platy PR -Prismatic Mineralogy 1:1, 2:1, Mixed Notes horizon depth - In inches Depth of fill - In inches Restrictive horizon - Thickness and inches from land surface Saprolite - S(suitable), U(unsuitable) Soil wetness - Inches from land surface to free water' or inches from land surface to soil colors with chroma 2 or less Classification - S(suitable), PS(provisionally suitable), U(unsuitable) LTAR - Long-term acceptance rate - gal/day/ft2 0 DAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENT PERMIT, and OPERATION PERMIT IMPROVEMENT PERMIT **NOTE** This improvement permit DOES NOT authorize the construction or installation of a septic tank system or any wastewater system. AN AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION must be obtained from this Department prior to the construction/installation of a system or the issuance of a building permit. (In compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) / A NAME/�i'1 PROPERTY ADDRESS DATE - LOCATION 0-1 SUBDIVISION NAME '/moi ! / LOT NUMBER SEC./BLOC( NUMBER RESIDENTAL SPECIFICATION: BUILDING TYPE! # BEDROOMS # BATHS # OCCUPANTS GARBAGE DISPOSAL: Yes/6 COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes/No LOT SIZE TYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD) NEW SITE REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIIEA�a. GAL. PUMP TANK OTHER GAL. TRENCH WIDTH TX ROCK DEPTH , LINEAR FT. �W REQUIRED SITE MODIFICATIONS/CONDITIONS: + ***THIS PERMIT IS SUBJECT TO REVOCATION IF SITE PLANS OR THE INTENDED USE CHANGE. YOUR WASTERWATER SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING THE SYSTEM. IMPROVEMENT 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 THE DAY OF INSTALLATION, TELEPHONE # IS (704) 634-8760. OPERATION PERMIT SYSTEM INSTALLED BY AUTHORIZATION NO. 40:! 3 OPERATION PERMIT BY A/ DATE / .**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE WITH ARTICLE 11 OF G.S. CHAPTER 130A, SECTION .1900 'SEWAGE TREATMENT AND DISPOSAL SYSTEMS', BUT SHALL IN NO WAY BE TAKEN AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTOPILY FOR ANY GIVEN PERIOD OF TIME. DCHD 10/95 { Davie County'Health Department ENVIRONMENTAL HEALTH SECTION , P.O. Box 665 Mocksville, N.&: 27028 ' AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION (Issued in compliance'wth Article 11 of G.S. Chapter'130A, Wastewater Systems) y ***This Authorization For Wastewater System Construction must be issued by the Davie County Environmental Health Section prior to issuance of any Building Permits. This Form/Authorization Number should be presented to the Davie County Building Inspections Office when applying for Building Permits.*** / �" � 5f AUTHORIZATION NUMBER NAME DATE i V a J, NAME ON IMPROVEMENT PERMIT (If different than above) SITE LOCATION �, i;;j COMMENTS/CONDITIONS ON AUTHORIZATION TO CONSTRUCT WASTEWATER SYSTEM l ***NOTICE*** THIS AUTHORIZATION ;FOR WAS WATER SYSTEM CONSTRUCTION IS VALID FOR A PERIOD OF FIVE (5) YEARS. ENVIRONMENTAL HEALTH SPECIAL ST DATE DCHD 10/95 APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT 4 t Davie County Health Department Environmental Health Section P. O. Box 665 lS Mocksville, NC 27028 plication/Permit Requested By_ Mailing Address Home Phone 9,/Q— .73,00 Business Phone �7�� %O - <" WJdA 2. Name on Permit if Different than Above 3. Application for: ❑ General Evaluation Efseptic Tank Installation Permit 4. System to Serve: M19ouse ❑ Mobile Home ❑ Place of Public Assembly ❑ Business ❑ Industry ❑ Other ❑ Unknown 9 5. If house, mobile home: Subdivision �// /01 z Section Lot # asement/Plumbing No. of People No. of Bedroor No. of Bathroo Dwelling Dime 6. If business, industry, place of public assembly, other: Specify type No. of People Served No. of Commodes No. of Lavatories No. of Sinks No. of Urinals No. of Water Coolers ❑ Basement/No Plumbing ❑ Washing Machine ❑ Dishwasher ❑ Garbage Disposal No. of Showers Water Usage Figures 7. Type of water supply: Publi�c/;JZj,; �� Private ❑ Community 8. Property Dimensions ��f �4� Sewage Disposal Contractor 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes pilo If yes, what type? 'NOTE: Improvements Permits shall be valid for a period of 5 years from date issued. Improvements Permits are subject to revocation, if site plans or the intended use change. Effective October 1, 1989. Directions to Property: This is to certify that the information provided is correct to the best of my incurred from thiap I' bion. —_ DATE ,l / /7 and I undgrstand I am responsjb)e for all charges TURE CONSENT FOR SITE EVALUATION TQ BE DONE ON ABOVE DESCRIBED PROPERTY MUST CHECK ONE: ❑ 1. 1 OWN the property. ❑ 2. 1 DO NOT OWN the property. If you checked Box #2, the rest of this form MUST be completed by the owner or a person authorized by the owner: I hereby give consent to the authorized representative of the Davie County Health Department to enter upon above described property located in Davie County and owned by to conduct all testing procedures as necessary to determine said site's suitability for a ground absorption sewage treatment and disposal system. DATE SIGNATURE DCHD11193) ■ �Y 2 3 4 Landscape position L , I DAVIE COUNTY HEALTH DEPARTMENT '`y -� ' L Environmental Health Section Texture group Soil/ Site 'Evaluation Structure Mineralogy DATE EVALUATED 6 SA, ESS PROPERTY SIZE 7 •ie- 20POSED FACIILTY �1 /1hf Q LOCATION OF SITE Mineralogy ,LY0&vell,61 Water Supply: On -Site Well Community Public L/� Evaluation By: Auger Boring Pit Cut L/ Mineralogy FACTORS 1 2 3 4 Landscape position L 4- L Slope Z Y '`y -� HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH 6 SA, Texturegroup L'.ellC Consistence Structure Mineralogy HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE All CLASSIFICATION LONG-TERM ACCEPTANCE RATE ,` 't — —1 SITE CLASSIFICATION: _ !�� EVALUATED BY: LONG-TERM ACCEPTANCE RA E:OTHERS) PRESENT:�/�� REMARKS: • y/l e ` isac e, LEGEND Landscape Position R -Ridge S -Shoulder L -Linear slope FS -Foot slope N -Nose slope CC -Concave slope CV -Convex slope T -Terrace FP -Flood plain H -Head slope Texture S -Sand LS -Loamy sand SL -Sandy loam L -Loam SI -Silt SICL-Silty :lay loam- SIL -Silty loam CL -Clay loam SCL-Sandy clay loam SC -Sandy clay SIC -Silty clay C -Clay CONSISTENCE Moist VFR- V}_. -y friable FR -Friable FI -Firm VFI-Very firm EFI-Extremely firm Wet NS -Non sticky SS -Slightly sticky S -Sticky VS -Very Sticky NP -Non plastic SP -Slightly plastic P -Plastic VP -Very plastic Structure SC --Single grain M -Massive CR -Crumb GR -Granular ABK-Angular blocky SBK-Subangular blocky PL -Platy PR -Prismatic Mineralogy j 1:1, 2:1, Mixed Notes 1 i Horizon depth - In inches ' Depth of fill - In inches Restrictive horizon - Thickness and inches from land surface Saprolite - S(suitable), U(unsuitable) ' Soil wetness— Inches from land surface to free water or inches from land surface to soil colors with chroma 2 or less Classification - S(suitable), PS(provisionally suitable), U(unsuitable) s LTAR - Long-term acceptance rate - gal/day/ft2 i DCHD(01-901 a; DAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION 'NOTE: Issued in Compliance With Article II of G. S. Chapter 130a Sanitary Sewage SystemsPermit Number w o Name N `��' a-=• ;r�� __i ;Date G – 7931 Location Subdivision Name Lot No. Sec. or Block No. Lot Size ac- House —4 " Mobile Home ---^ Business _.— Industry No. Bedroom$ No. Baths— No. in Family _— Public Assembly Other Garbage Disposal YES NO p Specifications for System:. o rf Auto Dish Washer YES NO p Auto Wash Ma^hine YES NO ❑�-: l.,�ilz /� �} emit/12 L ' Type Water Supply SLa 'This permit Void if sewage system described below is not installed within 5 years from date of issue. This permit is subject to revocation if site plans or the intended use change ATTENTION: YOUR SEPTIC SYSTEM CONTRACTOR MUST SEE THIS PERMIT/LAYOUT BEFORE INSTALLING THIS SYSTEM.. Fin Improvements permit by •9ontact a representative of the Davie County Health Department for final inspection of this system between 8:30-9:30 A.M., on day of completion. Telephone Number: 704-634-5985.., r":00-1:30 P.M. or 4:30-5:00 P�M -c.- I Certificate of Completion__ Date a4_ '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.