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P3647 Davie Academy 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 - fil �/ Date, "31 E� 4 i Location - Subdivision Name lLot No. Sec. or Block No. Lot SizeHouse Mobile Home --- ""'Business Speculation �- - _ No. Bedrooms No. Baths __ No. in Family _ Garbage Disposal YES ❑ NO Q Specifications for System: Auto Dish Washer YES ❑ NO ❑ Auto Wash Machine YES] NO ❑ /j � �IC Type Water Supply �'! '';� . __ , >%�--fir / *This permit Void if sewage systel 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 11A I` rg 1 t" Certificate of Completion G'''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. _i APPLICATION FOR SITE EVALUATION/ IMPROVEMENTS PERMIT Davie County Health Department Environmental Health Section P. O. Box 665 Mocksville, N.C. 27028 CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED. 1. Permit Requested By 2. Address — 3. Property Owner if Different than Above Address 4. Permit To: a) Install Alter Repair b) Privy Conventional ther Type Ground Absorption c) Sub -Division Sec. Lot No. 5. System used to serve what type facility: House Mobile Home_L`—Business IndustryOther b) Number of people , 6. a) If house or mobile home, state size of home and number of rooms. House Dimensions A�XeeS__� Bed Rooms Bath Rooms -7 / 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 lavatory dishwasher showers sinks garbage disposal washing machine 8. a) Type water supply: Public Private Community b) Has the water supply system beep approved? Yes JNo 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? Thisisto certify that the information is correct "bef y a4nowledDate Owner Sign OWNER IS SOLELY RESPONSIBLE FOR COMPLINCE WITH ALL STATE AND LOCAL LAWS Allow 5 days for processing Directions to property: DCHD (6-82) Name— Address DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section R 0. Box 665 Mocksville, N.C. 27028 SOIL/SITE EVALUATION Date Lot Size` FAr`TOP.q ARFA 1 AREA 2 AREA 3 AREA 4 Topography/ Landscape Position SS S S PS PS PS U U U U !) Soil Texture (12-36 in.) Sandy, S -S S S Loamy, Clayey, (note 2:1 Clay) C� PS PS PS U U U U 1) Soil Structure (12-36 in.) S S S S Clayey Soils (fD PS PS PS U U U U G) Soil Depth (inches) S S S S 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 i) Restrictive Horizons Available Space S S. PS S PS S PS U U U 1) Other (Specify) S S S S PS PS PS U U U 1) Site Classification U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable Recommendations/Comments: T Described by Title �'� Date SITE DIAGRAM i DCHD (6-82)