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P4417 Fork Bixby Rdf a DAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION 'rI OTE: Issued in Compliance with G.S. of North Carolina Chapter 130 Article 13c gewage Treatment and Disposal Rules (10 NCAC 10A .1934-.1968) Permit Number Name Date ���f 1^ 17 Location �!"> r✓�'` ,..%= �l%r`�/,—�'' s ,14�s-, Subdivision Name Lot No Sec. or Block No. Lot Size House Mobile Home,_ Business Speculation No. Bedrooms No. Baths J No. in Family '} _. Garbage Disposal YES ❑ NO ❑_- Specifications for System: Auto Dish Washer YES NO Auto Wash Machine YES NO ❑ Type Water Supply /L., !r' "This permit Void if sewage system described below is not installed within 36 months from date of issue. "Contact a representative of the Davie 9:30 A.M. or 1:00-1:30 P.M. on day Final Installation Diagram: Improvements permit by l Health Department for final inspection of this system between 8:30- fetion. Telephone Number: 704-634-5985. System Installed by ( 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. j APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT �= Davie County Health Department Environmental Health Section ' P. O. Box 665 RECEIVED JUN 2 186 Mocksville, N.C. 27028 CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED. / Home � W69 b i 1.. Permit Requested By (1 J4 -e- Business Phone 2. Address 3. Property Owner if Different than Above Address 4. Permit To: a) Install Alter Repair`�� b) Privy ConventionalL Other Type Ground Absorption c) Sub -Division Sec. Lot No. 5. System used to serve what type facility: House obile 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 -3 0�q -i- -'� '� Bed Rooms— hath 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 appprpved? Yeses N 9. a) Property Dimensions 7 a��� ! Z 7 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 informati is c rhe t to the best of my k of Date Owner Signature OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS Allow 5 days for processing Directions to property: �- -D14� d,,114 DCHD (6-82) ' DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Box 665 Mocksville, N.C. 27028 SOIL/SITE EVALUATION Name Date — Address Lot Size FACTORR ARFA 1 AREA ? AREA 3 ARFA d 1) Topography/ Landscape Position PS S � S PS S PS U U �) Soil Texture (12-36 in.) Sandy, Loamy, Clayey, (note 2:1 Clay) S c S rf rs-3 S PS S PS U U 1) Soil Structure (12-36 in.) Clayey Soils 0 S <�p�S� S S PS S PS U U U 1) Soil Depth (inches) r (4 0' S PS S PS U U ) Soil Drainage: Internal S S PS U S PS U External ®' PS PS S PS S PS U U U U 1) Restrictive Horizons Available Space �g S -PS S PS S PS U U U U 1) Other (Specify) S PS S PS S PS S PS U U U U 1) Site Classification --IS" �' � t U—UNSUITABLE Recommendations/ Comments: Described by SITE DIAGRAI DCHD (6.82) S—SUITABLE (,,"PS—Provisionally Suitable TRIP Date