P5010 Gun Club Rd i
DAVIE COUNTY HEALTH DEPARTMENT f
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
' .l ' i
Name ��! t�a /_/ t c /gin /r7 f,' ! Dater
Location
Subdivision Name Lot No. Sec. or Block No.
` Lot Size 1�' House Mobile Home _ Business Speculation
No. Bedrooms _ _ No. Baths No. in Family
Garbage Disposal YES ❑ NO ['-J, Specifications for System:
Auto Dish Washer YES NO ❑ �--
Auto Wash Machine YES LTJ NO ❑ /� _ V' 's -% ' .r
Type Water Supply //f/
. __—
*This permit Void if sewage system described below is not installed within 36 months from date of issue.
1-
r /
Improvements permit by
*Contact a representative of the Davie County Health Department for final inspection of this system between 8:30--
9:30
: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 �C,••> ``*�>
1
F
Certificate of Completion �— �` . * j�� _ Date J /!
*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.
'.; APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT C�� 0
Davie County Health Department
Environmental Health Section \V
P. O. Box 665 NNW��
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
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Home Phone!)
1. Permit Requested Bye y�L� `��C�2 11 Business Phone
2. Address \xo. c V2n'_ c�`C�L — �— `1 � 2Q U 5
3. Property Owner if Different than Above n g:tl M2-ts
Address 91a - - = V\ .0 . _ 1c�0
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 Dimensions2'S/_1'8 (VnL10 2-S C�_- �3(t) p S
Bed Rooms Bath Rooms \y 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 Z showers 'n QQ-,R Tom) washing machine )
dishwasher sinks
8. a) Type water supply: Public_'N Private Community
b) Has the water supply system been approved? Yes No
9. a) Property Dimensions AT, c 100 �2 OCA -
b) Land area designated to building site
c) Sewage Disposal Contractor Je('Cy p CZ\mak\ —` ��d? � ��tn� ,v�—�� ►1.�
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.
v�.�v—�IFM'
Date Owner bignature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
15 Allow 5 da for processing �^
Directions to property:
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DCHD(6.82)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
�e SOIL/SITE EVALUATION
Name Date
Address Lot Size , 6
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position A, S
US
2) Soil Texture (12-36 in.) Sandy, S
Loamy, Clayey, (note 2:1 Clay) PS PS
3) Soil Structure (12-36 in.) S S S
Clayey Soils PS PS
Q' U
4) Soil Depth (inches) S S
(7 PS
U
5) Soil Drainage: Internal S
PS PS
( U
External S
<k ep's) ' PS
U U U
6) Restrictive Horizons
7) Available Space S S
PS PS
U U
8) Other (Specify) S S S S
PS PS PS PS
U U U U
9) Site Classification , P. ,
U—UNSUITABLE S—SUITABLE ,PS—Provisionally Suitable
Recommendations/Comments: —rs !Y
Described by Titler
� Date
SITE DIAGRAM
6� n
� C
S
UCHO(6.82)
• ' Davie County Aealtif De artment
and .dome Nealtl yency
21 O HOSPITAL STREET I P.O. BOX 665
MOCKSVILLE, N.C. 27028
PHONE:(704)634-5985
July 22, 1988
W. Paul Enscore
109 Montroyal Dr.
Rural Hall, NC 27045
Re: Sewage System Installation
On Gun Club Road/Permit #5010
Dear Sir:
The septic tank system that serves this residence was designed,
inspected and approved by this office on June 9, 1988.
With proper maintenance and use it should function properly.
Sincerely,
Charles E. Little, R.S.
Environmental Health
CL/wd