1312 Fork Bixby Rd Davie County,NC Tax Parcel Report Friday,November 18, 2016
4
1312
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WARNING: THIS IS NOT A SURVEY
ParcelInformation #r_ i
Parcel Number: H700000087 Township: Shady Grove
NCPIN Number: 5779039204 Municipality:
:..—;.Account Number: ',•8304775 Census Tract: 37059-804
Listed Owner 1: - BRITTAIN ROBERTS Voting Precinct: WEST SHADY GROVE
_ Mailing Address 1: -1312 FORK BIXBY ROAD. Planning Jurisdiction: Davie County
City: Advance Zoning Class: DAVIE COUNTY R-A,R-20
State: ' NC Zoning Overlay:
Zip Code: 27006 ,'Voluntary Ag.District: No
Legal Description: 11 AC FORK BIXBY RD Fire Response District: FORK
Assessed Acreage: 10.72 Elementary School Zone: SHADY GROVE,CORNATZER
Deed Date: 2/2015 Middle School Zone: WILLIAM ELLIS
Deed Book/Page: 009801038 Soil Types: PcB2,GnB2,PcC2,MsC
Plat Book: Flood Zone:
Plat Page: Watershed Overlay: DAVIE COUNTY
Building Value: 140900.00 Outbuilding 8r Extra 0.00
Freatures Value:
Land Value: 86420.00 Total Market Value: 227320.00
Total Assessed Value: 227320.00
QsiA All data Is provided as is without warranty or guarantee of any kind either expressed or Implied Including but not limited to the
Davie County, Implied warranties of merchantability or fitness for a particular use.All users of Davie County's GIS website shall hold harmless the
County of Davie,North Carolina,Its agents,consultants,contractors or employees from any and all claims or causes of action due to
�o�ty C NC or arising out of the use or Inability to use the GIS data provided by this website.
w
OPERATION PERMIT or ice Use
Only
Davie County Health Department `CDP File Number. 202607-1
. .. * 210 Hospital Street
� - P.O. Box 848 .County ID Number.
Mocksville NC 27028 Evaluated For: EXPANSION
Phone: 336-753-6780 Fax:336-753-1680 Township:
Applicant: Robert Brittain Property Owner: Robert Brittain
Address: 1312 Fork Bixby Rd Address: 1312 Fork Bixby Rd
City: Advance City: Advance
State/Zip: NC 27028 State/Zip: NC 27028
Phone#: (336) 816-0611 Phone#: (336) 816-0611
-
Property Location & Site Information
Address/Road#: Subdivision: Phase: Lot:-
1312 Fork Bixby Road
Mocksville NC 27028 Directions
hwy 64 East left on Fork Bixby Rd On the right
Structure: SINGLE FAMILY before Baileys Chapel Rd
#of Bedrooms: 3
#of People:
*Water Supply: N/A
*IP Issued by:' 2140-Nations,Robert
*System Classification/Description: -
TYPE II A.CONV SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS)
*CA issued by: 2140-Nations,Robert
Saprolite System? 0 Yes ®No
Design Flow: 3 6 0 *Distribution Type: GRAVITY-SERIAL Pump Required?
0 Yes g No
Soil Application Rate: 0 3 *Pre-Treatment:
- Drain field
Nitrification Field. 8 0 0 Sq.ft. *System Type: 25%REDUCTION INNOVATIVE OR
No. Drain Lines Installer: Sherman Dun
Total Trench Length: a 0 0 ft. Certification#: 2702
Trench Spacing: _ 9 0 Inches O.C.
Feet O.C. EHS: 2399-Eldridge,Tiffany
Trench Width: 3 Q Inches
_
U Feet Date: 0 8 / a 6 / a 0 1 6
Aggregate Depth: inches
Minimum Trench Depth: a 4 Inches
Minimum Soil Cover: 1 a Inches Approval Status
Maximum Trench Depth: 3 6 Inches E Approved ElDisapproved
Maximum Soil Cover: a 4 Inches
Page 1 of 4
CDP File Number 202607 - 1 Septic Tank County ID Number: ,
Manufacturer: existing Lat.
STB: Long:
Gallons: Installer:
Date: Certification#:
*EHS:
*Filter Brand:
ST Marker: [I Yes El No
Date:
Reinforced Tank: F1--Yes El No Approval Status
1 Piece Tank:- ❑ Yes ❑ No
❑`Approved❑ Disapproved
Pump Tank
Manufacturer: Installer:
PT: Certification#:
-Gallons: *EHS:
Date: I Date:
Riser Sealed ❑ Yes ❑ No
`Riser Height: ❑ Yes- ElNO (Min. 6 in.)
Approval Status
Reinforced Tank: ❑ Yes: ❑ No
❑ ;Approved❑ Disapproved
r a,
1Piece Tank:-❑ _YeS - ❑_No - -
Supply Line
Pipe Size: inch diameter
Installer.
Pipe Length: feet Certification#:
*EHS:
*Schedule:
Pressure Rated ❑ Yes ❑ No Date:
Approved fittings ElYes ElNo Approval Status
❑ Approved ❑ Disapproved
Pump Requorement
CDosing
p Type: Installer:
olume: - Gal Certification#:
raw Down: Inches *EHS:
*Chain:
Date:
Valves Accessible ❑ Yes ❑ NO
Flow Adjustment Valve ❑ Yes ❑ No
Check-valve ❑ Yes ❑ No Approval Status
PVC unions ❑ Yes ❑ No ❑ Approved❑ Disapproved
Vent Hole EJYes ElNo
Anti-siphon Hole ❑ Yes ❑ No
Page 2 of 4
CDP File Number 202607 - 1 County ID Number:
Electric E ui ment
NEMA 4X Box or Equivalent ❑ Yes ❑ No Installer:
Box 12 inches Above Grade ❑ Yes ❑ NO
Box Adj.To Pump Tank ElYes El No Certification#:
Conduit Sealed ❑ Yes ❑ NO `EHS:
Pump Manually Operable ❑ Yes ❑ No
"Activation Method: Date:
Alarm Audible ElYes El No Approval Status
❑ Approved❑ Disapproved
Alarm Visible ❑ Yes ❑ NO
2399-Eldridge,Tiffany
"Operation Permit completed by:
Authorized State Agent:' Date of Issue: 0 8 / x 6 2 _0 1 6
_ Owner/Applicant Signature:
This system has been installed in compliance with applicable NC General Statutes:Article 11, Chapter 130A, Rules for �. .,
Sewage Treatment and Disposal,-.15A NCAC 18A.1900 et. Seq.,and all conditions of the Improvement Permit and
- Construction Authorization.Thisproperty is served by a TYPE 11 A. sewage septic System.
Rule.1961 requires that a Type TYPE a A. septic system meet the following criteria:
Minimum System Review By The Local Health Department: N/A
Management-Entity: OWNER
Minimum System Inspection/Maintenance Frequency By Certified Operator:
N/A
Reporting Frequency By Certified Operator: N/A
Rule.1961 requires that a Type IV and V septic systems designed for a home/business owner must maintain a valid contract
with a public management entity with a certified operator or a private certified operator for the life of the septic system.
Rule.1961 requires that Type.VI septic systems designed for a home/business owner must maintain a valid contract with a
public management entity with a certified operator for the life of the septic system.
-Rule. 1961 (2)(e)requires a contract shall be executed between the system owner and a management entity prior to the
issuance of an Operation Permit for a system required to be maintained by a public or private management entity, unless the
system owner and certified operator are the same. The contract shall require specific requirements for maintenance and
operation, responsibilities of the owner and systems operator, provisions that the contract shall be in effect for as long as the
system is in use,and other requirements for the continued proper performance of the system. It shall also be a condition of
the Operation Permit that subsequent owners of the systems execute such a contract.
®Hand Drawing O Import Drawing
**Site Plan/Drawing attached.**
Page 3of4
OPERATION PERMIT 202607 - 1
Davie County Health Department CDP File Number:
210 Hospital Street
P.O.Box 848 County File Number:
Mocksville NC 27028 Date:
O Inch
Drawing Drawing Type: Operation Permit Scale: , OO NSA k = ft.
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Page 4 of 4 P1 P2 P3
OPERATION PERMIT
Davie County Health Department
r 210 Hospital Street CDP File Number:
P.O.Box 848
Mocksville NC 27028 County File Number:
Date: . .
Click below to import an image from an external location: Drawing Type:Operation Permit
Page 4 of 4 P1 P2 P3
System Final Inspection Log: Chwadws Field:
Remaining
,-r
4000
Septic Tank: Chwacte s
Remaining
4000
Pump Tank: Chwadws
Remaining
4000
Supply Line: awadws
Remaining
4000
Pump Requirements: Chwadws
Remaining
4000
Electrical Equipment: Remeing
4000
P1 P2 P3
t836I� Tax Map:
• Address:
.s„ Inst; ��.
EHS:
Date: tani
Operation Permit Inspection Checklist
❑ Conventional ❑ Chamber ❑ Polystyrene ❑ Other
Location and Separation Distances
1. Distance from septic tank/pump tank to foundation/basement feet
2. Distance from system to.well if applicable feet
3. Any other setback(.1950)requirements
Supply line
1. Material supply line is constructed of diameter inches
2. Length of supply line(2'min.)
3. Amount of fall in supply line(1/8"per foot min)
4. Distance from ST/PT to the nitrification field/dist.device) feet
Septic Tank/Pump Tank
1. Visually inspect top of tanks(s),interior&exterior walls,baffle wall and bottom
2. Any honeycombing or exposed rebar.present? Circle: YES or NO
3. Visually inspect sanitary tee,lids,and air vent for proper installation and sealant
4. Tank Serial Numbers: STB PT
5. ST w/in 6"finished grade?Circle: YES or NO
6. Date of manufacture: ST PT
7. Liquid capacity of tanks ST PT
8. Effluent filter type
9. Pipe penetration seal present?Circle: YES or NO
10. Riser(s)present?Circle: YES or No Riser Type
11. Pump Tank riser 6"above finished grade?Circle: YES or NO
12. Riser approved?Circle: YES or NO
Nitrification Field
1. Septic Tank outlet elevation
2. Trench Depth Readings(inches)
3. Number of Trenches Distance between trenches
4. Trench Width
5. Aggregate material type and size 3 4 5 6 57 (Circle)
6. Aggregate Depth(inches)
7. Nitrification lines installed on contour?Circle: YES or NO
8. Innovative system type Installer certified for installation?Circle: YES or NO
9. 2'earthen dam between ST(or d box)and beginning of nitrification line?Circle:YES or NO
10. Stepdowns
a. 2'undisturbed earthen dam(s) Circle: YES or NO
b. Proper rise over stepdowns?Circle: YES or NO
c. Solid pipe used? Solid,Corrugated or other?
d. Elevation of each stepdown
e. Are all stepdowns lower than the ST outlet elevations? Circle: YES or NO
Distribution Devices
1. Type Is the device watertight? Is it level?
2. Distance from Dist.device to trenches feet
3. Record elevations:Inlets Outlets
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CONSTRUCTION IFor office use onl41 y
AUTHORIZATION *CDP File Number 202607-1
U1 .
Davie County Health Department County ID Number.
210 Hospital Street Evaluated For. EXPANSION
P.O. Box 848
Township:
Mocksville NC 27028 PERMIT VALID UNTIL:
Phone: 336-753-6780 Fax:336-753-1680 0 5 / 1 2 / a 0 a 1
Applicant: Robert Brittain Property Owner: Robert Brittain
Address: 1312 Fork Bixby Rd Address: 1312 Fork Bixby Rd
City: Advance City: Advance
State2ip: NC -27028 StatelZip: NC 27028
- Phone#: (336)816-0611 Phone#: (336)816-0611
Property Location & Site Information
Address/Road #: Subdivision: Phase: Lot:
1312 Fork Bixby Road
Mocksville NC 27028 Directions
hwy 64 East left on Fork Bixby Rd On the right before
Structure: SINGLE FAMILY Baileys Chapel Rd
#of Bedrooms: 3
#of People:
*Water Supply: N/A
System Specifications
Minimum Trench Depth: a 4
/SiteClassification: Provisionally Suitable Inches
- Minimum Soil Cover. 1 a
Saprolite System? QYes QNo Inches
Design Flow: 3 6 0 Maximum Trench Depth: 3 6 Inches
Soil Application Rate: 0 - 3 Maximum Soil Cover: a 4 Inches
*System Classification/Description: *Distribution Type: GRAVITY-SERIAL
TYPE II A.CONV SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS) Septic Tank:
Gallons
*Proposed System: 25%u REDUCTION 1-Piece: Q Yes Q N o
Pump Required: QYes QNo QMay Be Required
Nitrification Field 8 0 0
Sq,ft. PumpTank: Gallons
No. Drain Lines a 1-Piece: QYes QNo
Total Trench Length: a 0 0 ft GPM—vs— ft. TDH
Trench Spacing: _ 9 Onches
FeeO CC. Dosing Volume: _ Gallons
Trench Width: Inches
3 _ @Feet Grease Trap: Gallons
Aggregate Depth: inches
Pre-Treatment: ONSF OTS-1 OTS-II
Septic Tank Installer Grade Level Required: OI OII O III OIV
Donn � of Z
CDP File Number 202607 - 1 County ID Number: - ' ,
❑ Open Pump System Sheet
Repair System Required:@Yes ONo ONO, but has Available Space
rDesign
System
Trench Spacing: 9 Q Inches O.C.
ification: Provisionally Suitable — (�Feet O.C.
Trench Width: Q Inches
w: 3 6 0 _ 3 . Feet
Soil Application Rate: 0 - 3 Aggregate Depth: inches
*System Classification/Description: Minimum Trench Depth: a 4 Inches
TYPE 11 A.CONY SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS, Minimum Soil Cover. 1 a Inches
'Proposed
-System: 250%REDUCTION Maximum Trench Depth: 3 6 Inches
-- Maximum Soil Cover: a 4
Nitrification Field 1 a 0 0Sq.ft.
Inches
No. Drain Lines *Distribution Type: GRAVITY-SERIAL
3
-Total Trench Length: 300 -- Pump Required: ayes @No OMay Be Required
_ . . ft. _
Pre Treatment: ONSF OTS-1 OTS-II
*Site Modifications
No grading or construction activity is allowed in areas designated for system and repair without approval of Health Department.
*Permit Conditions
The issuance of this permit bythe Health Department in no way guarantees the issuance of other permits.The permit holder
is responsible for checking with appropriate governing bodies in meeting their requirements.
This Authorization for wastewater System Construction shall bevalid for a person equal to the period of validity of the Improvement Permit,not
to exceed five years,and may be issued atthe sametime the Improvement Permit Issued(NCG5130A-336(b)).If the installation has not been
completed during the period of validity of the Construction Permit,the Information submitted In the application for a permit or Construction
Authorization Is found to have been incorrect,falsified or changed,or the site Is altered,the permit or Construction Authorization shall become
Invalid,and may be suspended or revoked(.1937(g)).The person owning or controlling the system shall be responsible for assuring compliance
with the laws,rules,and permit conditions regarding system location,Installation,operation,maintenance;,monitoring,reporting and repair
(1938(b)).
Applicant/Legal Reps. Signature Required? Oyes ONO
Applicant/Legal Reps. Signature• Date:.
*Issued By: Date of Issue:2140-Nations,Robert 0 5 / 1 a / a 0 1 6
_
Authorized State Agent: Malfunction Log OYes
@Hand Drawing Olmport Drawing
**Site Plan/Drawing attached.**
Page 2 of 3
CONSTRUCTION AUTHORIZATION 202607 - 1
Davie County Health Department CDP File Number:
210 Hospital Street
P.O.Box 848 County File Number:
Mocksville NC 27028 Date: 05 / 1 2 / .1 0 1 6
Q Inch
Drawing DrawingType: Construction Authoriz tion Scale: . . . QBlock = ft.
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CONSTRUCTION AUTHORIZATION '
Davie County Health Department
210 Hospital street CDP File Number: 202607- 1
P.O.Box 848 '
Mocksviile NC 27028 County File Number:
Date: .0 .5 / 2 / 2 0 1 6
Click below to import an Image from an external location: Drawing Type:Construction Authorization
Davie County Health Department
f
4 18�� Environmental Health Section
i . . -
P.O.Box 848
210 Hospital Street fj
U � ( Courier# : 09-40-06 - ��1
vas Mocluville,NC 27028
Phone:(336)-753-6780 Fax:(336)-753-1680
ON-SITE WASTEWATER CERTIFICATION
(Check One) Replacement Remodeling Reconnection
Name: /Fe 214 IF,—; '7 t) -k Phone Number -4�, J I (Home)
Mailing Address: /21,2 ��,e k.Y (Work)
�Vel.i ems, /W, -2 200 Email Address: �s b�%T�at� G�n�t i�•C�/�
Detailed Directions To Site:
Property Address: 1312
Please Fill In The Following Information About The EXISTING Facility: /
Name System Installed Under: d I XAy i S Typ e Of Facility: hoz? 5e—
Date System Installed(Month/Date/Year): / y q Number Of Bedrooms: 3 Number Of People:
Is The Facility Currently Vacant? Yes �p If Yes,For How Long?
Any Known Problems? . Yes (5) If Yes,Explain: -.-
Please Fill In The Following Information About The NEW Facility:
Type Of Facility: �G+�GI Y; e S Number Of Bedrooms: 3 Number of People 1- 3
'Pool Size: Garage Size: Other:
Requested By: �r/.f'` ' r tZl`�• Date Requested: 1 �'
(Signature)
For Environmental Health Office Use Only
Approved Disapproved
Comments:
Environmental Health Specialist Date:
*The signing of this form by the Environmental Health Staff is in no way intended,nor should be taken as a guarantee
(extended or limited)that the on-site wastewater system will function properly for any given period of time.
Payment: Cash Check Money Order # Amount:$ Date:
Paid By: Received By:
Account#: A� Invoice#:
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DAVIE COUNTY HEALTH DEPARTMENT
—A ,
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION -fGU� -/�.
NOTE: -Issued in Compliance with G.S. of North Carolina Chapter 130 Article 13c
p Sewage Treatment and Disposal Rules (10 NCAC,1OA .1934-.1968) Permit Number
,. Name -,/Date •jr,_Z�` N2 570
_ L
` Location �:zE
Subdivision Name Lot No. Sec. or Block No.
Lot Size �' " House 1� Mobile Home _ Business Speculation
No. Bedrooms No. Baths No. in Family
Garbage Disposal YES -❑ NO '❑ Specifications for System:
Auto Dish Washer YES p'" NO ❑ �if�� \ ..
Auto Wash Machine YES ❑ NO C]
Type Water Supply
*This permit Void if sewage system described below is not installed within 36 months from date of issue.
a
4
Improvements permit by / f'
*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
Certificate of Completion Date `--/2
*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.
w APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section
R 0. Box 665
Mocksville, N.C. 27028
GONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
_f '7
Home Phone q%� 77 6
1. Permit Re uested By V Business Phone
2. Address l I 2 K `a.(3—A
3. Property Owner if Different than Above
Address
4. Permit To: a) Install Alter Repair
b) Privy Conventional Other Type
Ground Absorption
c) Sub-Division Sec. Lot No.
5. System used to serve what type facility: Housed Mobile Home Business—
Industry—
usiness Industry Other—
b)
ther b) Number of people `'► _ `��
6. aj If house or mobile home, state size of home and number of rooms.
House Dimensions
Bed Rooms 19 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 urinals garbage disposal
lavatory showers washing machine
dishwasher sinks
8. a) Type water supply: Public Private Community
b) Has the water supply system been approved? Yes No
9. a) Property Dimensions / '7 X 'j,'a `�
b) Land area designated to building site A� E
c) Sewage Disposal Contractor �ra c
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
lirections to property: Allow 5 days for processing
to property:
el�4// �-�
's
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section.
P. 0. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name , _ Date
� �-
Address Lot Size Zec
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position ( d S
PS PS PS PS
U U U U
2) Soil Texture (12-36 in.) Sandy, Ov /�, S
Loamy, Clayey, (note 2:1 Clay) S PS PS
U UU� U U
3) Soil Structure (12-36 in.) �` ! 6 S
Clayey Soils PS PS PS PS
U U U U
4) Soil Depth (inches) S
PS PS PS PS
U U U U
5) Soil Drainage: Internal <�P? S
PS PS PS PS
U U U U
External <V _–Q) S
S PS PS PS
U U U U
6) Restrictive Horizons
7) Available Space S S
S PS is PS
U U U U
8) Other (Specify) S S S S
PS PS PS PS
U U U U
9) Site Classification .�
U—UNSUIT E S—SUITABLE —Provisionally Suitable
Recommendations/Comments:
Described by Title Date
SITE DIAGRAM
l
i
DCHD(6-82)
DAVIE COUNTY HEALTH DEPARTMENT
N - 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 Date
��.
:
Location r`,�L' .� ,Y< f✓
1312- Fq ;L1
Subdivision Name Lot No. - Sec. or Block No.
Lot Size ',, r%' House �� Mobile Home — Business Speculation
No. Bedrooms �--� No. Baths No. in Family _
Garbage Disposal YES ❑ NO
Specifications for System:,-
Auto Dish Washer YES NO ❑
Auto Wash Machine YES j NO ❑
Type Water Supply
`This permit Void if sewage system described below is not installed rwith, 36/mothe from date of issue.
i
Improvements permit by
*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.
C C '
Final Installation Diagram: System Installed by
, t
i
1,
Certi icate oflCompletion -�. ��\ t "t Date
�I
,thegning of this certificate shall indicate that the system described above has been installed in compliance with
ndards set forth in the above regulation, but shall in NO way be taken as a guarantee that the system will function
ctoriiy for any given period of time.
DAVIE COUNTY HEALTH DEPARTMENT
t Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name ��<'S Date /f •
Address Lot Size Zz/�
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position S S
dp
eS PS PS
U U U U
2) Soil Texture (12-36 in.) Sandy, S S S
Loamy, Clayey, (note 2:1 Clay) PS PS PS
U U
3) Soil Structure (12-36 in.) S S
Clayey Soils PS lei PS PS
U U U U
4) Soil Depth (inches) S S
4PPS PS
U U U
5) Soil Drainage: Internal S S
PS ) PS PS
U U
External SS S
PS PS
-Cf U U
6) Restrictive Horizons
7) Available Space S S
PS PS PS PS
U U U U
8) Other (Specify) S S S S
PS PS PS PS
U U U U
9) Site Classification
U—UNSUITABLE S—SUITABLE (PS—Provisionally Suitable
Recommendations/Comments:
Described by1� Title ,C!w Date/
SITE DIAGRAM
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DCHD(6-82)
y^ V APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department WILG�2
y Environmental Health Section
P. O. Box 665 U ep lap
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
9.
Home Phone27–7a `—�r"4 o e-
1.
1. Permit Requested y Business Phone
2. Address) f•" �-. 'Zs,9 j —� a j
3. Property Owner if Different than�jAbove
Address ob�i� (Vure-cy
4. Permit To: a) Install Alter Repair
b) Privy Conventional Other Type
Ground Absorption
c) Sub-Division Sec. Lot No.
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
Bed Rooms Bath Rooms 2 Den w/Closet—�
b) If Business, Industry or Other, State: Number of persons served N�i9
What type business, etc.
Estimate amount of waste daily (24 hours)
7. Number and type of water-using fixtures:
commodes 3 urinals garbage disposal
lavatory 3 showers 2 washing machine
dishwasher sinks /
8. a) Type water supply: Public ` Private Co munity
b) Has the water supply system been approved? YesZNo
9. a) Property Dimensions
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 information is correct to the best of my knowledge.
i A
Date U Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property: *49
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DCHD(6-82)