351 Four Corners Rd (2) 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-.1 68) _ Permit Number
Name Date ?'/,� ��T116
Location �. f- � ,�;,✓ 'f - fr"r' '"��r��-�
Subdivision Name Lot No. Sec. or Block No.
Lot Size ? %- ' n House MA)je'Home.-_ Business Speculation
No. Bedrooms No. Baths J No. in Family.
Garbage Disposal YES El tiO !❑. Specifications`fo S ste
Auto Dish Washer YES NO ❑ `1 �r,���t��u,�' u,, ,, ,� /, ,
Auto Wash Machine YES NO ❑
Type Water Supply
*This permit Void if sewage system described below is not installed within 36 months from date of issue.
r
I
Improvements permit by /Z
*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 ��nz,�� T Al; X
f"I QZ �-
-� , V
Certificate of Completion /G ~ /2 Date 'I ss
'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
P. 0. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name 1411Z;r Date
Address Lot Size
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Positiony� . S S S
t
( PS� $1 PS PS
UU U
2) Soil Texture (12-36 in.) Sandy, S,, S S S
Loamy, Clayey, (note 2:1 Clay) �' S � PS PS
U �t1 U U
3) Soil Structure (12-36 in.) S S
Clayey Soils PS�� PS PS PS
U U U U
4) Soil Depth (inches) -S- S S
pS� ( PS PS
U U
5) Soil Drainage: Internal S._-. ^ S S
PSPS PS
U U U U
External S S S S
PS PS PS PS
U U U U
6) Restrictive Horizons
7) Available Space C� CS 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 by itle Date
SITE DIAGRAM /17
G�
)
L__
DCHD(6-62)
V
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section
R O. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phon ?^ 2 q l
1. Permit ReMs! By Business Phone �'0
2. Address i
3. Property Owner if Different than Above
Address
4. Permit To: a) Install Iter Repair/
b) Privy Conventional Other Type
Ground Absorption
c) Sub-Division Sec. Lot No.
5. System used to serve what type facility: House-!::f-Mobile Home Business
IndustryOther
b) Number of people ?`
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions
Bed Rooms -S - 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 systems been appr ved? Yes No
9. a) Property Dimensions « �• fl�� R�-� '�'
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? a�
What type?
This is to certify that the information is correct to the best f my knowledge. C
Date V awner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
I
DCHD(6-82)
TERRY B. DEDMON
S'
ALBERT M
G. REAS
33.3929"
E DB 115 PG 643' FO
211.01 .
p I p 9C'y
ANNIE McCULLOUGH Fr�
DB. 80 PG. 260
.�
P o,
rb
to I�O�aG�' '36�• O4.
�Z 2 4•.
.WAYNE McCULLOUGH
��•Z� AREA = 1 . 374 ACRE
DB. 72 PG, 29 Off• ( INCLUDES SR 1807 R/W) .
107 860
F eip ,• .
- - 32.18 ,-
527. 10 10.29 point in.edge
01 nip +-- N 42'44" 01"w569. 57 TOTAL nip of pond
. ,.. LEGEND.--
E. M. JAMES
DB. 71 PG. 22
o eip = EXISTING IRON . PIN
2 o nip = NEW IRON PIN
el P o� i 5 hb O
FRED W ALLEN Q� • = RIR :SPIKE ROAD-
DB 76 PG 547 a
80 - 147 ..
JERUSALEM TOWNSHIP, DAVIE CO.INC.
+,����Il,nu,,,,►,, REVISIONS SURVEY . FOR
CAR. 'n � TOLERANCES
C•A�7 lsxcc►r As Norcol NO. DATE BYJUDGE :B,#_J0H1
.••• •,.• 1,GRADY k TUTTEROI►/, CERTIFY THAT UNDER
0 °``�',yjE�'EG /y�� MY DIRECTION AND SUPERVISION,THIS MAP De"MAL . + 0.606 FROM REAVIS 8 DEDMON DB'
,115 PG.643
Z : SEAL ' ',� � WAS DRAWN FROM AN ACTUAL.FIE.D SURVEY t
a _ i 1.374- AC. FROM E.M.JAMES 1)8,71 PG- 22:`
•
L-2527 ,MADE BY TUTTEROW SURVEYING CO. FRACTIONAL
DRAWN BY SCALE MATERIAL
.•'qf0 Sl1P�'=� TUTTEROW SURVEYING CO. t 9 GLT .1.. 5O
�i C,t .• .. fJ: GHK'D DATE. DRAWING NO.
.,��fO .....•��t2,,�.` _-- ROUTE 6 BOX 129 F ANGULAR GLT' 12 20-83
REG -RED SURVEYOR L 1327 s °
MOCK..VILIE, N. C. d92•Sblb t es TRACED, ; AFF•D 20583—.2r . .