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176 Pine Valley Road Lot 10• DAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION i{1 -itis 'NOTE: Issued in Compliance With Article I I of G.S. Chapter 130a Sanitary Sewage Systems _ Permit Number Name rr + �1`., ' �' 4- Date 0 o i NO t Location Dat 2 --/ �-! %i r. C) Subdivision Name �' % sal �. •�%� '� I Lot No. �' J Sec. or Block No. Lot Size House t Mobile Home _ Business __ Speculation rNo. Bedrooms `- No. Baths `f No. in Family _ Garbage Disposal YES ❑ NO 2.-" Specifications for System: Auto Dish Washer YESNO ❑ �,r% Auto Wash Machine YES g NO ❑ Type Water Supply Kir) *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 k Certificate of Completion Date 63 �• J *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. i Y APPLICATION FOR SITE EVALUATION/ IMPROVEMENTS PERMIT w 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. / Home Phone G 75 4 -) 1. Permit Requested By o ^ �i `A ^ Business Phone `I -2 Z- f Z o r 2. Address 0.4 /fic o �l /� ; , —T AF 3. Property Owner if Different than Above =o h in -+ n Address S A '_ v: j /C , A), r-- 4. Permit To: a) Install Iter Repair �er b) Privy Conventional Type Ground Absorption + / c) Sub -Division; C kl^J fl" 11 Sec. Lot No. / y 5. System used to serve what type facility: Housed Mobile Home Business IndustryOther b) Number of people 2- 6. a) If house or mobile home, state size of home and number of rooms. 6. House Dimensions y i) -.I- Z 8' Bed Rooms 3 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 3 urinals garbage disposal lavatory showers Z- washing machine dishwasher sinks 8. a) Type water supply: Public L-� Private—Community b) Has the water supply system been approved? Yes No 9. a) Property Dimensions © , S-- y Q;' b) Land area designated to building site 2 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)pe best oy knowled A57 DQ Date Owner Signature OWNER IS SOLELY RESPONSIBLE FOR COMPLINCE WITH ALL STATE AND LOCAL LAWS Allow 5 days for processing Directions to property: DCHD (6-82) LOT x8 existing S existing rebor CM. = 4C75 - /52.56 j tabor 26.39 ARC : 41,. 88 Cy = 3� 4RC — o N 59. 38' 25" W exlsting 3� 96 Ss rebor N 51. 50' 48" W new. Ironc? 9 �s ; N 36. 51' 15" ap PINEVALLEY ROAD o�. ploced Iron 60' R/W f ;.; ta=^ "3' " _' Sv hie hx `� t'ia t .-�,� :, ,.:: ., . ., - «•- s, c e.. � ,.'�` �.,, 1�u.';, ci r a _ } ,. _.. -• � r .: . t�Mr`ilafiY� i G ut r• ��sn�e Address FAr'TnRC DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section. P. 0. Box 665 Mocksville, N.C. 27028 SOIL/SITE EVALUATION Date Lot Size ARFA 1 ARFA 9 AREA 3 ARFA d 1) Topography/ Landscape Position I Irl 9) S S PS PS S U U U U �) Soil Texture (12-36 in.) Sandy, Loamy, Clayey, (note 2:1 Clay) ku I) Soil Structure (12-36 in.)j Clayey Soils Lys <9PPS U U y Soil Depth (inches) (SS `o U U i) Soil Drainage: Internal (PSS 'tT S Sj < , "tT External PS P P U U �) Restrictive Horizons Available Space PS PS PS S PS U U U U {) Other (Specify) S PS S PS S PS S PS U UU Site Classification 1 1 X)51 U—UNSUITABLE Recommendations/Comments: Described by _ SITE DIAGRAM DCHD (6-82) S—SUITABLE PS—Provisionally Suitable Title 51-2� Date