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240 Cleary RdDAVIE 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 .1934-.1968) Permit Number Name Date '-/�'�-.�,� b $ 35� Location Subdivision Name Lot No. Sec. or Block No. Lot Size i% House Mobile Home _ Business Speculation No. Bedrooms No. Baths No. in Family _ Garbage Disposal YES p NO ❑ Specifications; for. System: 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. 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 Certificate of Completion Qn.�o 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 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 .1934-.1968) rl Permit Number i -Name ,���.-- /rs «,-• 1',�>,-� .,�., ,;�'j ��- - Date 6 3551 Location _� e i .�6 i''�} -, �•' f� ~'"ids' . ;�. S",, �' !fes""6P''(_'.'�' r) �✓ .'�,%� _ il— � • j L� 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 .0 NO E]'i` Specifications for.System:. f • `. Auto Dish Washer YESr 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. Improvements permit by u *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. I� Final Installation Diagram: System Installed by v �I Certificate of Completion Date • .a 'The signing of this certificate shall indicate that the system described above has bee,l 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 Date — Address Lot Size FAr.TnR.q AREA 1 AREA 2 AREA 3 AREA 4 Topography/ Landscape Position S S S S PS PS PS U U U U !) Soil Texture (12-36 in.) Sandy, S S S Loamy, Clayey, (note 2:1 Clay) PS PS PS PS U U U 1) Soil Structure (12-36 in.) S S S Clayey Soils PS PS PS U U U l) Soil Depth (inches) S S S PS PS PS PS U U U �) Soil Drainage: Internal S S S S PS PS PS U U U External S S S S PS PS PS U U U U I) Restrictive Horizons Available Space S- S S S PS PS PS U U U t) Other (Specify) S S S S PS PS PS PS U U U I) Site Classification 45 e I I . I U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable Recommendations/Comments: Described by TitleDate SITE DIAGRAM /'• It � v � DCHD (6-82) APPLICATION FOR SITE EVALUATION/ IMPROVEMENTS PERMIT �l- Davie County Health Department - Environmental Health Section I" P. O. Box 665 Mocksville, N.C. 27028 CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED. Home Phone l`104iy9a-53&5 1. Permit Requested By )e.\SOT 1'\arle.10e _T Business Phone 2. Address IRL L . &Y, 150 - t In 'nflQASL i 1L 1e i k).(2.. x,9(7" T 3. Property Owner if Different than Above Le\SUTO - YQX-IeXee M=x-eNk-438 Address g-1 U &x \%t)- 16 MOQI U11e (L.C. 211M 4. Permit To: a) Installer 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 a 6. a) If house or mobile home, state size of home and number of rooms. House Dimensions \"a X LAS Bed Rooms a 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 1 showers washing machine A, dishwasher sinks 8. a) Type water supply: Public Private_ Community b) Has the water supply system been approved? Yes No %/ !' 9. a) Property Dimensions esju b) Land area designated to building site c) Sewage Disposal Contractor pollard nx\,� V00% Plumbi'XT� 10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve? �i n What type? This is to certify that the information is correct to the best of my knowledge. 14 - a rl- RLJ 'yaw" t un h Q m�yYLQ Date Owner Signature OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS Allow 5 days for processing Directions to property: ley ' wGq , ry-" L odb INba�_ 9a. DCHD (6-82)