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125 E Renee Drive Lot 26,qd _ ✓x� 4 t DAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION *NOTE: Issued in Compliance With Article 11 of G.S. Chapter 130a Sap'tary Sewage Systems / Permit Number Name �, �. ��i S �D toy/� N0 ,�� E � r3 0 Location � l—,IZ��� j2 �.. Subdivision Name ���/�Lot No. r Sec. or Block No. Lot Size House Mobile Home _ Business _._ Speculation No. Bedrooms 1—T No. Baths _ No. in Family__ Garbage Disposal YES ❑ NO ❑ Specifications for System: Auto Dish Washer YES ❑ NO ❑ Auto Wash Ma thine YES ❑ NO ❑ Type Water Supply *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. 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 �s sdaw,� 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. 4 DAVIE COUNTY HEALTH DEPARTMENT ` IMPROVEMENTS PERMIT AND . CERTIFICATE OF COMPLETION *NOTE: Issued in Compliance With Article 11 of G.S. Chapter 130a Sanitary Sewage Systems / Permit Number Name Date ,� .�; f <` /�i' ��f!i�'�✓�l Date �' ��''`2 N2 Location _ r — Subdivision Name % Lot No. , ( Sec. or Block No. Lot Size House Mobile Home —� Business _— Speculation r� No. Bedrooms No. Baths x No. in Family �`— Garbage Disposal YES ❑ NO ❑ Specifications for System: Auto Dish Washer YES ❑ NO ❑ Auto Wash Ma shine YES ❑ NO ❑ Type Water Supply __— *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. 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 s�ow� Certificate of Completion j .�.� 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. 1 ' APPLICATION FOR SITE EVALUATION/ IMPROVEMENTS PERMIT �l Davie County Health Department j' Environmental Health Section P. O. Box 665 RECEIVED JO +� Mocksville, N.C. 27028 H g/ CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED. Home Phone 1. Permit Requested By f>i�i�h�� %yam Business Phone—//_ 2. Address y?� 3. Property Owner if Different than Above Address 4. Permit To: a) Install L-,'� 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 Home Business Industry Other b) Number of people 6. a) If house or mobile home, state size of home and number of rooms. House Dimensions 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 urinals garbage disposal — lavatory showers washing machine_ dishwasher sinks 8. a) Type water supply: Public Private Community b) Has the water supply system been approved? Yes No 9. a) Property Dimensions 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? 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:le4'© %__ At � �I cc) spy, LCIGk ��.O�O-!il ev G'Gl Aa r� DCHD (6-82) •' DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section R O. Box 665 Mocksville, N.C. 27028 SOIL/SITE EVALUATION Name Date Address Lot Size Z40/490 F F E FAr'.TORR AREA 1 AREA 2 AREA 3 AREA 4 Topography/ Landscape Position 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) KPIS7—) PS PS PS U U U 1) Soil Structure (12-36 in.) yy��--�� S S S Clayey Soils (PSS PS PS PS U U U Soil Depth (inches) S S S (LT PS PS PS U U U ) Soil Drainage: Internal S S S (' S PS PS U U U U External S S S PS PS PS 'II U U U �) Restrictive Horizons Available Space S S S S V, PS PS PS U U U I) Other (Specify) S S S S PS PS PS PS U U U U 1) Site Classification i U—UNSUITABLE Recommendations/ Comments: S—SUITABLE PS—Provisionally Suitable Described by ' �d.!Title Date a4z SITE DIAGRAM DCHD (6-82)