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P4421 Farmington RdDAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETIOW 1� `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 /�laf'lf �' �r ;-r D1. 1 r. ate '�' Location Subdivision Name Lot No Sec. or Block No. Lot Size 1�`,�'(` House Mobile Home _ Business Speculation No. Bedrooms No. Baths No. in Family — Garbage Disposal YES ,4 NO ❑ Specifications for System: Auto Dish Washer YES Q NO Auto Wash Machine YES _�] NO p Type Water Supply ' _— ''This permit Void if sewage system described below is not installed within 36 months from date of issue. r - l ! 1 Improvements permit by "Contact a representative of the Davie County Health Department for final inspection of this�yste jbetween8:30- 9:30 A.M. or 1:00-1:30 P.M. on day of completion. Telephone Number: 704-634-985: ' ' Final Installation Diagram: System Install 11 d,by/�r;%•� 2,7 J Q;./( . Certificate of Completion 1/OLt" 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 Environmental Health Section P. O. Box 665 Mocksville, N.C. 27028 SOIL/SITE EVALUATION Name Date Address Lot Size W E 9) FACTORS AREA 1 AREA 2 AREA 3 ARFA d 1) Topography/ Landscape Position S SS PS S PS U U U U !) Soil Texture (12-36 in.) Sandy, S f S S Loamy, Clayey, (note 2:1 Clay)P ' PS PS U U U 1) Soil Structure (12-36 in.) S S S S Clayey Soils PS PS U U U G) Soil Depth (inches) S S S PS PS U U U i) Soil Drainage: Internal Se:�FF S PS S PS U U External S S S S PS PS PS PS U U U U �) Restrictive Horizons Available Space S S S S PS PS PS PS U U U U 1) Other (Specify) S S S S PS PS PS PS U U - U U Site Classification U—I Recommendations/ Comments: Described by SITE DIAGRAM C� DCHD (6.82) S—SUITABLE O—Provisionally Suitable — Title W Date,ClL ��.✓ fie/^ •r APPLICATION FOR SITE EVALUATION/ IMPROVEMENTS PERMIT �F© Davie County Health Department ✓ Environmental Health Section P. 0. Box 665 Mocksville, N.C. 27028 CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED. Home Phone 998-8994 1. Permit Requested By Rodney Edward Wilson Business Phone 766-4761 2. Address Property - Rt I Mocksville, N.C. 27028 Mailing - PO Box 527 3. Property Owner if Different than Above same Clemmons, N.C. 27012 Address 4. Permit To: a) Install x Alter Repair b) Privy Conventional-y—Other Type Ground Absorption c) Sub -Division Sec. Lot No. 5. System used to serve what type facility: Houser Mobile Home Business Industry Other b) Number of people 5 6. a) If house or mobile home, state size of home and number of rooms. House Dimensions 11 O' x 33' Phis Larage (22 x 24) Bed Rooms 5 Bath Rooms 5,32, 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 6 uri lavatory E showers Q 0 garbage disposal 0 washing machine 1 dishwasher 1 sinks 1 8. a) Type water supply: Public 1 Private Community b) Has the water supply system been approved? Yes x No 9. a) Property Dimensions -10 a cr P G 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? NO What type? This is to certify that the information is correct to the best of my knowledge. \� z �_V-�J1 Date t1ner Signature OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS Allow 5 days for processing Directions to property: Interstate left on Hwy right prior DCHD (6-82) 40 East to Farmington Road Exit, 801 North, property is .5 miles to and joining. Cedar Creek. left on Farmington to Hwy 801, north on Hwy 801, on the Davie County Health Department Environmental Health Section P. 0. Box 665 Mocksville, N. C. 27028 On -Site Sewage System Operation Permit The on-site sewage treatment and disposal system installed at the above mentioned location is of such design that an Operation Permit is required. Effective January 1, 1984 G. S. 130A -337b requires an Oper- ation Permit for any system that consists of any of the following: 1. Pumps and/or grease traps 2. Alternative System 3. System with a design flow rate greater than 480 gallons per day 4. System serving multi -family dwelling. Furthermore, any system which exceeds 3000 gallons per day and/or any system which is required to be designed by a professional engineer shall be subject to an annual re -inspection. This Operation Permit is valid as long as the sewage treatment and disposal system is in compliance with Article 11 of G. S. Chapter 130A, and all conditions imposed by the Operation Permit. -2 __..��IIZF�c�",f1•.�YQ.�1��7lei= J . Date o ssuance Environmental Health Official Title DAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION' l i 4 r 'NOTE: Issued in Compliance with G.S. of North Carolina Chapter 130 Article 13c Sewa a Treatment and Disposal Rules (10 NCAC 10A".1934-.1968) Permit Number Name / 1 c` . a- - „ , Date Location s Subdivision Name Lot No. Sec. or Block No. Lot Size House Mobile Home _ Business Speculation i No. Bedrooms No. Baths S No. in Family _ Garbage Disposal YESNO I C-] Specifications for System: —% Auto Dish Washer YES NO ❑---;��r=�-� Auto Wash Machine YES g NO `•' Type Water Supply _ "This permit Void if sewage system described below is not installed within 36 months from date of issue. Ir - Improvements Improvements permit by "Contact a representative of the Davie County Health Department for final ins 9:30 A.M. or 1:00-1:30 P.M. on day of completion. Telephone Number: 704 - Final Installation Diagram: 1 System Installed )ection of this ystbbry " 8:30- i34-6 5- 0L") � U <' r.- J l Sn Certificate of Completion _1 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 Environmental Health Section P. 0. Box 665 Mocksville, N. C. 27028 On -Site Sewage System Operation Permit The on-site sewage treatment and disposal system installed at the above mentioned location is of such design that an Operation Permit is required. Effective January 1, 1984 G. S. 130A -337b requires an Oper- ation Permit for any system that consists of any of the following: 1. Pumps and/or grease traps 2. Alternative System 3. System with a design flow rate greater than 480 gallons per day 4. System serving multi -family dwelling. Furthermore, any system which exceeds 3000 gallons per day and/or any system which is required to be designed by a professional engineer shall be subject to an annual re -inspection. This Operation Permit is valid as long as the sewage treatment and disposal system is in with Article 11 of G. S. Chapter 130A, and all conditions imposed by the Operation Permit. Date o ssuance Environmental Health—Official Title