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P3125 Hwy 801SDAVIE COUNTY HEALTH DEPARTMENT gd l 5 r IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION *Note: Issued in Compliance with G.S. of North Carolina Chapter 130—Article 13c. Name.- Date Permit, Number Location .;� � ._ , c ;... -r Subdivision Name Lot No. Sec. or Block No. Lot Size House Mobile Home _ �� Business Speculation No. Bedrooms _'1 No. Baths No. in Family - Garbage Disposal YES ❑ NO p' Specifications for System: lock-,' Auto Dish Washer YES Q NO ❑ Auto Wash Machine YES ❑ NO ❑ 3C>J x i h• t4. Type Water Supply C' , --- Ja %" '�;` 'This permit Void if sewage system described below is not installed within 36 months from date of issue. ..,y- .•r "--...- ....,..__------------------------------ Improvements -----._--- Improvements permit *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: i System Installed a 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. DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. 0. Box 665 Mocksville, N.C. 27028 SOIL/SITE EVALUATION i m e Z AuJP-wcg-- �OL. Date 6`-.3'0 - $ 2 idress ��- 20 �AL£c:�c�D �2�� Lot Size 74 Ac - (JI -0-r-r - („ )/N -s -r v -j— - SAG Q44-- /JC 0710K CA nT/'1 ['fC AticA Afl["A n Anr-A n Topography/Landscape Position S S S S PS PS PS U U U U Soil Texture (12-36 in.) Sandy, Loamy, Clayey, 2:1 Clay) Aa YM S S (note PS PS U U U U Soil Structure (12-36 in.) Clayey Soils & & S PS S PS U U U U Soil Depth (inches) S © S S PS S PS U U U U Soil Drainage: Internal ® S S PS PS PS PS U U U U External 65 F S S PS PS PS PS U U U U Restrictive Horizons Available Space S S PS PS PS PS U U U U Other (Specify) S S S S PS PS PS PS U U U U Site Classification U—UNSUITABLE scommendations/Comments: S—SUITABLE /' PS—Provisionally Su =scribed by � � TitIe ''Date'—� TE DIAGRAM ` 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 C/G Liz C Mode— jV-- 2. Address ZO f — Z O 104- LtAn{ )w. , M10 r -S 3. Property Owner if Different than Above "W r'e hc-tr 1_e�e ry Address Kf 9-dUu nc. -e M C. ai ov 4. Permit To: a) Install Alter Repair b) Privy Conventional -IL Other Type Ground Absorption Home Phone '76 S — (�_ 61 ? Business Phone _Sold k lay i.i, It. Hil }� Lam td X . 9-710 c) Sub -Division Sec. Lot No. 5. System used to serve what type facility: House Mobile Homed Business IndustryOther b) Number of people 01- 6. a) If house or mobile home, state size' of home and number of rooms. House Dimensions Y. b8 Bed Rooms Bath Rooms Z 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 Z - showers dishwasher sinks garbage disposal washing machine 8. a) Type water supply: Public `� Private Community b) Has the water supply systp b en Gapproved? Yete / No 9. a) Property Dimensions-�� Z n b) Land area designated to building site c) Sewage Disposal Contractor Sec'bo-'- C 0 r n 0�t-z-e r- 10. 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 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: h ct' . L -.L- Y}'1 oc, IL or mall I b -0y t(A r)-- Sc lwa 1 DCHD (8-82)