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P4923 Gladstone Rd- - - ---- � - --^^--v--+-.-motif---�..r-wsw:ramy�----......+....rv.�.• . so..^.-...s:asrta+wtiKfv•v�-v.+r�+^,r..... w�..--•.. -• �-.-•--- - -- ----- - - . - DAVIE COUNTY HEALTH DEPARTMENT ; 9Z)- „ - IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION Y "NOTE: Issued in Compliance with G.S. of North Carolina Chapter 130 Article13c ;1 Sewage Treatment and Disposal Rules (10 NCAC 10A .1.934-.1968) Permit Number Name Jx .�-- , r' _ / ://�;�' 4923 Location-�,�°<(—' Subdivision Name1` Lot No., Sec. or Block No. Lot Size House f Mobile Home �_ Business ''Speculation No. Bedrooms _ _ No. Baths- No: in Family. ;i Garbage Disposal , YES p NO* n . �'' Specifications for System: Auto Dish Washer, YES NO 'p Auto Wash Machine YES NO ,F `" �`� ?e Type. Water"Supply "This permit Void if sewage system descr�i bed below is, not installed within 36 months from date of ,issue. i Improvements permit by t `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: 704-63,4-5985. Final Installation Diagram: System I,nstalICd by -/CI �.S .,., • _ �, ,.. ori 41 l� Certificate of Completion , Date.Z�> The signing of this certificate shall indicatie thatthe'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 r ~O Davie County Health Department Environmental Health Section G R O. Box 665 G�4� Mocksville, N.C. 27028 CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED. I Home Phone ? L—�-7/L- / `4 7 1. Permit Requ sted B d le ` SW Business Phone 2. Address �Z a 3. Property Owner if Different than AboveA/Wt� Address '15"� 4. Permit To: a) Install --L Alter Repair b) Privy Conventional Other Type Ground Absorption c) Sub -Division Sec. Lot Np.�_ 5. System used to serve what type facility: House Mobile 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 14 by 70 Bed Rooms 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 Z urinals garbage disposal lavatory showers Z washing machine dishwasher 0 sinks 8. a) Type water supply: Public Private Community b) Has the water supply system been approved? Yes ±L__No 9. a) Property Dimensions AM �T V ©� Frt- b) Land area designated to builsite c) Sewage Disposal ContractordinC ssi K J_ 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 co ct the best of kno I ge. 9-'q_9'2 Date weerignature OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS Directions to' property: DCHD (6 Allow 5 days for processing e4- / 111 V%eei' oto 0 ` DAVIE COUNTY HEALTH DEPARTMENT ENVIRONMENTAL HEALTH SECTION SITE EVALUATION CONSENT FORM 1. Complete the form below and return to the Davie County Health Department. 2. Carefully follow the procedures as outlined in the enclosed "Information Bulletin." NOTE: THE ABOVE MUST BE COMPLETED BEFORE A SANITARIAN WILL BE ABLE TO BEGIN THE REQUESTED EVALUATION. DETACH HERE AND RETURN TO: Davie County Health Department, Environmental Health Section, P. O. Box 665, Mocksville, N.C. 27028 Davie County Health Department Environmental Health Section Site -Evaluation Consent Form L��TIQN OF PCRTY: DATE RECEIVED 11 S�/8�t� (office use only) 25tis) no 1. 1 am the owner of the above described property. yes' no 2. 1 am flet the owner of the above described property, however, I certify that I have consent from , owner to obtain a owner's name site evaluation by the Davie County Health Department for the purpose of determining the suitability for a ground absorption sewage treatment and disposal system. es no 3. 1 hereby give consent to the authorized representative of the Davie County Health Department to enter upon the above described property and conduct all testing procedures as necessary to determine its suitability for a ground absorption sewage treatment and disposal s m. d2 _v DATE V11 tI6M)rU_RI5' 4. 1 hereby authorize the Davie County Health Department to release site evaluation results from the above described property to the following: Owner only �ers designated representative —Anyone requesting results — Only those listed below y V DATE DCHD (11 /84) Name_ Address DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. 0. Box 665 Mocksville, N.C. 27028 SOIL/SITE EVALUATION L Date Lot Size FACTORS AREA 1 AREA 2 AREA 3 ARFA A 1) Topography/ Landscape Position S S S S 111�2 PS PS PS C—d U U U ?) Soil Texture (12-36 in.) Sandy, S S S Loamy, Clayey, (note 2:1 Clay) PS PS PS {� U U U 3) Soil Structure (12-36 in.) S S S Clayey Solis PS PS PS U U U I) Soil Depth (inches) S S S PS PS PS U U U i) Soil Drainage: Internal S S S PS PS PS U U U External S S S PS PS PS U U U i) Restrictive Horizons r .--- Available SpaceS S S S S PS PS PS U U U U i) Other (Specify) S S S S PS PS PS PS U U U U 1) Site Classification U—UNSUITABLE Recommendations/ Comments: - Described by SITE DIAGRAM 7CHD (h-82) S—SUITABLE PS—Provisionally Suitable Title :fin/ Date l-1ke, r