136 Papoose Trail /.r•., .. ..m..+_v:4.h.,:x;.... i. ...,✓ •<r'b...��._. ..w '` 5:'i. v.. �_4s x Ys-- .ki :.0.. _ .. .. . "...nc.,,.-.::.
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_. DAVIE COUNTY HEALTH DEPARTMENT
Y 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) 1 Permit Number
Name .Ja/f.nJ Date /%—�— .Y� : .- ,i C.
r
Location
Subdivision NameLot No. Sec. or Block No.
Lot Size i7�7C House., ' Mobile Home, Business _— Speculation
No. Bedrooms `� No. Baths f No. in Family
Garbage Disposal YES, ,E) NO 2 Specifications for Systern,
Auto Dish Washer YES NO p
Auto Wash Machine YES NO -E]
Type Water Supply __—
*This permit Void if sewage system described below is not installed within 36 months from date of issue.
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.
Final Installation Diagram: /�v System Installed by
I
��; �
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.
RECErvcl) SEP
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT 2 jQ�s
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.
Home Phone ?/G 8 9- ,5"-S'6 q
1. Permit Requested By Business Phone
2. Address R "'�
3. Property Owner if Different than Above
Address
4. Permit To: a) Install '�Alter Repair
b) Privy Conventional f/ Other Type
Ground Absorptio
c) Sub-Division T-d( 9,- 91/1-" Sec. Lot No. _
5. System used to serve what type facility: House X Mobile Home Business
Industry Other
b) Number of people 4
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions a x 56
Bed Rooms._Bath Rooms Den 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 3 urinals garbage disposal
lavatory 3 showers washing machine /
dishwasher sinks L
8. a) Type water supply: Public ✓ Private Community
b) Has the water supply system been approved? Yes No
9. a) Property Dimensions 310 1 X 6.�l
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? %yo
What type?
This is to certify that the information is correct to the best of my knowledge.
A, a
Date Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
J NGS J//N NNIS /"! ln�I �19��-tS - �H�JOOSQ T/ �P) 1 /O Nd.
(Y /
Le S) Fr . e,
1171 h/ �4ASf.
- S� !ems I
fiv r.J s�o^,
DCHD(6-82)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name Date
Address Lot Size
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position S S S
PS PS PS
U U U
2) 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 Soils PS PS PS
U U U
4) Soil Depth (inches) S S S
PS PS PS
U U U
5) Soil Drainage: Internal S S S
p PS PS PS
U U U U
External S S S S
VS
PS PS PS
U U U
6) Restrictive Horizons
7) Available Space S S S
PS PS PS
U U U U
8) Other (Specify) qS
S S S
PS PS PS
U U U U
9) Site Classification
U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable
Recommendations/Comments:
Described by � Title �0�� Date -�
SITE DIAGRAM
DCHD(6-82)
r
clBMvie Qlonntg Pettlth department
Unb CRIIme xealt4 Agentu1
P. O. BOX 665
Aacksiiille, �Zarth (garalina Z71Tz8
OFFICE OF THE DIRECTOR TELEPHONE
October 6, 1986 17041 634-5985
Mr. Leslie Frye
P.O. Box 2974
Winston Salem, NC 27102
Mr. Frye:
On October 1, 1986 this office evaluated lot 4 in Indian Hills
to determine the suitability of installing a septic tank sytem, on
said lot. On that date the lot was classified provisionally suit-
able.
Sincerely,
Robert B. Hall, Jr. R. S.
Environmental Health
RBHJR:sg