142 Jetry Ln DAVIE COUNTY HEAM DEPARTMENT
` v (Septic Tank) Improvements Permit and Certificate of:Completion
(Ground.Absorption Sewage Disposal System - G.S. Chapter 130-Aj;ticle 13C)
OWNER OR CONTRACTOR 'f, ,,� ,y -�, t;. DATE r!' "'7> PERMIT
LOCATION I; 4-, , 4N 671
S.R. NO.
SUBDIVISION NAME LOT NO. SECTION OR BLOCK NO. ,
HOUSE ❑ MOBILE HOME BUSINESS ❑
NO. BEDROOMS . NO. BATHROOMS House Trailer 800 Gal 400 Sq Ft.
Two Bedroom House ,.$UO Gal x'600 Sq Fa;
GARBAGE DISPOSAL UNIT YES ❑ NO ❑ Three Bedroom House x`-900 "Gal.--.--1900—Sq. Ft.
AUTO. DISHWASHER YES ❑ NO ❑ Four Bedroom House 1000 Gal. 1200 Sq. Ft.
AUTO. WASH. MACHINE YES ❑ NO ❑
SITE SUITABLE YES - [3 NO [3 L.
u4 4
SIZE OF TANK IM gal., uC
NITRIFICATION FIELD sq. ft.
DEPTH OF STONE' IN LINES:
WATER SUPPLY: Individual ❑ Public
IMPROVEMENTS PERMIT BY ���. ,,,_ wL INSTALLED BY
—It td�
CERTIFICATE OF COMPLETION ;BY Date
(8/16/73) *Construction must comply with all oth r applicable State and local regulations
LOT AREA
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.,' ' S• , DAVIE 'COUNTY HEALTH DEPARTMENT
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a IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
`NOTA': YIssued in Compliance with G.S. of North''Garolina Chapter 130 Article 13c
'Sewage ,Treatment-and Disposal, Rules i(1 O NCAC 10A .1934-.1968) Permit Number
,r 4313
- Name �..c.cz� - '�+a�:� ;��„� � I�i�� Date �- 7 '�� `dt�. . ���
LocationS s tai + ,�,n c'c' TY .., n .c »'. t 1 1 r
7 'L, iIG
OF,
Subdivision Name Lot No. - Sec. or Block No..,
Lot Size House ✓ Mobile Home Business __ - Speculation
No. Bedrooms .3 No. Baths Z No. in Family
Garbage Disposal YES NO 0-
Specifications for System: t o Qc�.c\a0. 7-, ..+�
Auto Dish Washer YES g- NO p
Auto Wash Machine YES p NO 'Q !', ` ?
Type Water Supply `�►�11 V; �t ,1�,�.. r:,t; , z'- a'”
*This permit Void if sewage system-described below is not ins ailed within- 36 months from date of issue.
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t
Improvements permit by'\3 {�
*Contact a representative of the Davie CountyHealth Department for final inspection of this system between 8:30-
9:30 A.M. or 1:00-4:30 P.M. on.day. of completion. Telephone Number: 704-634-5985.
b,I
Final Installation Diagram: ' System Installed by
o
hill _ 4
Certificate of Completion \ Date �1
"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 betaken as a guarantee that the system will function
satisfactorily for any given period of time. - �:;
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT ;�^�,
Davie County Health Department
Environmental Health Section `r
P. O. Box 665
Mocksville, N.C. 27028
� A
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED. S�
Home Phone
1. Permit Requested By G49 oK L 0-6M&Z Business Phone _(53m
2. Address /e7" db X Sl-B AD�i4_N� -A& C,
3. Property Owner if Different than Above
Address
4. Permit To: a) Install V Alter—
lter Repair
b) Privy Conventional- Other Type
Ground Absorption
c) Sub-Division Se Lot No.
5. System used to serve what type facility: House Mobile Home Business
Industry Other
b) Number of people 1A
6. a) If house or mobile home, state size oo/�1&
ff home and number of rooms.
House Dimensions r
C49? 7`°
Bed Rooms—Bath Rooms A 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:
commodes92urinals garbage disposal
lavatory a• showers washing machine
dishwasher sinks Tubs --
8. a) Type water supply: Public Private Community
b) Has the water supply system Peen approved? Yes No
9. a) Property Dimensions 860 .X oZ 4- 5'"X (a&D, &i ,
b) Land area designated to building site ��..
c) Sewage Disposal Contractor My-t�•�/✓s®
10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve? �Q
What type?
This is to certify that the information is correct to the best of my knowledge.
Date 17OWner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
Tec RW R ic-#r ov 0,4,L /M o Xe Ro,,,r-.1. G &j pp
811 gN AfgNiA! v rNe H-o"k' 4" /X 0 "V TNN
T aA d 1-c r r 47- r/ie1 t SE-C,0440 ,�.�° l�i� t�l�q}� Oe.>rC X "Dl;f&
j+ yG te, W //+ e_,o Al 8 7`0 / eX OWN,4,,Vo .WH/'3"'
0.� ONLY
194-56 t?oV 7` 'i��'! 7'IAE /V 0,4D.
DCHD(6-82)
f
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Namer * Aat -' 041-n-�-4 . Date
Address 1!`t: 5�- a Ad cc, Y7 C- x.706 6- Lot Size
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position CS0 $ Q
PS PS S PS
U U U U
2) Soil Texture (12-36 in.) Sandy, S S, S S
Loamy, Clayey, (note 2:1 Clay) U � ,~� U� U
3) Soil Structure (12-36 in.) S S $ S
Clayey SoilsPS I "CED
l u � u u 30 ' u.
4) Soil Depth (inches) S S S S
5) Soil Drainage: Internal S S S
PS PS
U U
External S ,�S S
SPS CGJs'
U U U
6) Restrictive Horizons1Llfj
7) Available Space r S S 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 0, q I f�� f --S
U—UNSUITABLE S—SUITABLE PS-Provisionally Suitable
Recommendations/Comments:
Described by Title `s^^ Date
SITE DIAGRAM, _ �—
1
1
f
1 `1t}6
1
DCHD(5-82)