1290 Liberty Church Rd DAVIE 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 < Date
Location
r
Subdivision Name / —1<r �C�/�-!1�� dot No. Sec. or Block No.
Lot Size , House Mobile Home Business Speculation
No. Bedrooms p No. Baths -� No. in Family
Garbage Disposal YES ❑ NO ❑--- Specifications for System:
Auto Dish Washer YES E] NO ❑ ,� f
Auto Wash Machine YES [] NO ❑
_;�.� '; ,moi
Type Water Supply __ -
*This permit Void if sewage system described below is not installed within 36 months from date of issue.
! i
1
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Improvements permit by
*Contact a representative of the Davie Cc u tyxi alth Departme t for final inspection'of this system between 8:30-
9:30 A.M. or 1:00-1:30 P.M. on day of c mpleti Telephone mber: 704-634-5985.
Final Installation Diagram: Syste Installed by
L-�
1
Certificate of Completion �u 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
R O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name Dale Ireland Date
Address Rt- 8, Box 439 Mocksville Lot Size 1 acre
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position S� S S S
PS PS PS
U U U U
2) Soil Texture (12-36 in.) Sandy, � S S S
Loamy, Clayey, (note 2:1 Clay) /r F'S PS PS PS
U U U
3) Soil Structure (12-36 in.) S S S S
Clayey Soils PS PS PS
U U U
4) Soil Depth (inches) S S S S
Kf PS PS PS
U U U
5) Soil Drainage: Internal S S S S
PS PS PS
U U U
External S S S
PS PS PS PS
U U U
6) Restrictive Horizons
7) Available Space S S S S
PS PS PS
U U U
8) Other (Specify) S S S S
PS PS PS PS
U U U
9) Site Classification ,
U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable
Recommendations/Comments:
Described by Title Sanitarian Date
SITE DIAGRAM
DCHD(6-82)
RECEIVED M IA`s C e986
Y 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.
Home Phone YQ_�2'•����
1. Permit Requested ByBusiness Phone
2. Address tl• F�
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: House Mobile Home—t:!f Busines
Industry Other
b) Number of people
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions 1�e - 15L-.
Bed Rooms_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 -9- 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 / Q2nqo5
b) Land area designated to building site Ate-t"d
c) Sewage Disposal Contractor
10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve? Z—
What type?
This is to certify that the information is correct to the best of my knowledge.
Date L111— Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
U
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DCHD(6-82)
OM�M7�lTOF TRANIKO ATION FINAL SUBDIVIDON PLAT APPROVAL 1, GRADY L. TUTTEROW
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ARC =79.30 �+ r N 24° 51 40 W `ZN 20° 02� 45 W N 19° 24� 44" W
7071 •�wviw�gsis-N 30°56112(W CHORD A=c = 26.s2 -- LIBERTY CHURCH ROAD \
O+ ,� CHORD= 79.29
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173 46 ..�N 32 49 53 W RADIUS = 1199.013
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79.27
A=C= sW WE HEREBY CERTIFY THAT WE ARE THE OWNERS
O �N 31REON
`US=1766 565 OF I HEREBY CERTIFY THAT THE DAVIE COUNTY AND THAT HAT WHE E HEREBRTY YO1A'ADOPT THIS CPLAN RIBED OF
O RAD HEALTH DEPARTMENT HAS EVALUATED THE SUBDIVISION WITH OUR FREE CONSENT, ESTABLISH
SUMVISION ENTITLED MINIMUM BUILDING LINES, AND DEDICATE ALL L EG E N D
.� WITH RESPECT TO CRITERIA AND CONDITIONS STREETS, ALLEYS,WALKS,PARKS, AND OTHER SITES . EIP = EXISTING IRON PIN
ESTABLISHED BY STATE LAW OR PROMULGATED FURTHER, WE CERTIFY THE LAND AS SHOWN O = NEW IRON PIN
THEREUNDER. AND THE SAME IS FOUND TO HEREON IS WITHIN THE PLATTING JURISDICTION • = R/R SPIKE IN (Z
COMPLY WITH SUCH CRITERIA AND CONDITIONS OF DAVIE COUNTY. O = NAIL 3 CAP IN CL
EXCEPT AS SET FORTH IN SUCH EVALUATION. + = POINT IN
NORTH CAROLINA , DAME COUNTY FOR DETAILS OF THIS EVALUATION AND FOR :
LIMITATIONS, SEE THE WRITTEN REPORT ON
I'G_Lmg&xAgr Aos,% CHAIRMAN OF THE FILE AT THE SAID DEPARTMENT./ NOTE ALL AREAS INCLUDE S.R. 1002 R/W.DAVIE COUNTY BOARD OF COMMISIONERS RTA T H TIF C TDOESE
HEREBY CERTIFY THAT SAID BOARD DULY #je8OVAL OF
APPROVED THE FINAL PLAT OF THIS SUBLOTS INJAI-
IVIIIQ
DIVISION ENTITLED, INMEMSFACIO'NOT'OFF SEWAf I11 FOR
ES
ON THIS THE 1`� DAY OF �_ 1913 .-. OWNER
TOTAL AREA = 4 .248 ACRES
I
CHAIRMAN DATE COUNTY HEALTHOWNER
`1114CAJR ` TOLERANCES REVISIONS SURVEY FOR
,��•`��'�•• C� s, 1,GRADY L TUT7T-ROW, Cf RTIFY THAT U.-MER 60 0 60 120 (EXCEIT AS NOTEDI NO. DAT[ ar
MY a�IF�,IJ �,,Q Su•EAV,s .,,�ts tv,¢ J . D. SHIELDS DIVISION
C '•� '' 7 WAS DK,�JN F4.�M ,- � : r,D SURVE' DECIMAL � BEING 4 TRACTS,TOTAL OF 4.248 AC. OF THE
)AA DE 3Y `. _►T �RO� ` __� :p. SCALE IN FEET ± J. D. SHIELDS PROPERTY, ( DB 112 PG 669 )
-2527 2 LYING IN CLARKSVILLE TWSR DAVI O. N. .
FRACTIONAL
DRAWN BY SCALE , MATERIAL
yti� SG�`t,•: a __.- - TUMROW SURVFYING CO. + s S P H 1 = 60
'`C.' •••••M'••���,` REGI RED SURVEYOR - - L 2527 ROUTE 6 Box 1" F 4 CHWD DATE DRAWING NO.
L• jUC� �� ANGULAR GLT 8-04-82
MOCKSV);iF. ��, ^. ,92 5616 ± TRACED APP•D 10182- 3
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