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P3701 Hwy 601SDAVIE 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 l6I��y Date �� 7 !- a l se '117 Q 1 Location 60/ -S Ota! 2lc,F,T f /;lief L<£�afrt a`��uTf� ys�ti�x.�r <<ir/.r2 Subdivision Name Lot No. Sec. or Block No. Lot Size / !!� House '"'' Mobile Home _ Business Speculation No. Bedrooms 3 No. Baths No. in Family 2.- _ Garbage Disposal YES ❑ NO Auto Dish Washer YES TNO ❑ Specifications for System:/pp;���l%- Auto Wash Machine YES NO -❑ %300 ''{ Type Water Supply e0&A17-/ ----- eax' 0" "This permit Void if sewage"',Vstem described below is not installed within 36 months from date of issue lkr)rovi v f f -Vs -rrv` -'S�NA (-(0'-0 , l 2'r ry +VrZ- permit by � u S - "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 -?,) a C 0 C K�- c J Certificate of Completion ```j }� ^��� Date 1- i �' " Y t) '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 �-D' p f: Date Address Z� e14`16i* S7 -C %G Lot Size S�� /Wcesvff-CE /VC r I:Ar.TnRc APPA 1 ARFA 9 ARFA 3 AREA A Topography/ Landscape Position 2) 3) 4) 5) S S PS PS PS PS U U U U Soil Texture (12-36 in.) Sandy, S S S S Loamy, Clayey, (note 2:1 Clay) (9)P3 PS PS U U U U Soil Structure (12-36 in.) S & S qrP S PS S PS Clayey Soils U U U U Soil'Depth (inches) S S S S PS PS U U U Soil Drainage: Internal S 6 S f'S S PS S PS U U U U External ® 2S7 S S PS PS PS PS U U U U i) 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 .0 U U ►) Site Classification Q S p t U—UNSUITABLE S—SUITABLE CPS Provisionally Su Recommendations/ Comments: Described by �VXZ5-" TitleDate SITE DIAGRAM xv g--�� APPLICATION FOR SITE EVALUATION/ IMPROVEMENTS PERMIT Davie County Health Department Environmental Health Section R 0. Box 665 Mocksville, N.C. 27028 CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED. 1. Permit Requested B 2. Address `L3 C_ -'A u»c—k S7,,,, 04 c, Az r/ IZe 3. Property Owner if Different than Above Arlriracc 4. Permit To: a) Install Alter Repair b) Privy Conventional Other Type Ground Absorption Home Phone 6 b Business Phone /-34 — c) Sub -Division Sec. Lot No. 5. System used to serve what type facility: oouse Mobile Home Business In ustryOther b) Number of people mobile a f house r mobile home, state size of home and number f roo s. 200 ->n f �- .i G House Dimensions / o owt� ' Bed Rooms 3 Bath Rooms Den w/Close /��f��z� b) If Business, Industry or Other, State: Number of persons served V 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 Com unity � b) Has the water supply system been approved? Yes. f�o 9. a) Property Dimensions / &E&, b) Land area designated to building site c) Sewage Disposal Contractor 10. Do you anticipate any additions or expansions of he facility this sewage system is intended to serve? �o What type? This is to certify that the information is correct to the best of my knowledge. Date Owner Signature OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS Allow 5 days for processing Directions to property: /n DCHD (6-82) •, M/