460 Boxwood Church Rd r • F ' ' DAVIE' COUNTY HEALTH DEPARTMENT'
f IMPROVEMENTS PERMIT AND .CERTIFICATE OF COMPLETION
J *NOTE: Issued in Compliance-with GIS: of North Carolina Chapter 130 Article 13c
Sewage Treatment,and Disposal Rules (10 NCAC 10A .1934-.1968) Permit Number
Name //��.1/ :i(/ Z Date, l/.3'`�
Location
Subdivision Name II Lot No: __ Sec. or Block No.
Lot Size House Mobile Home L--"� Business Speculation
I!
No. Bedrooms No.;BathsL No. in Family,;__
11 i;
ii Garbage Disposal YES •N0 [�]� Specifications for ?, 1
i' Auto.Dish Washer YES Nii ❑ � <%�;
�!
-Auto Wash Machine YES N
Type Water Supply
*This permit Void if sewage system;Idescribed 'below'is not installed within 36 months from date of issue.
li ,
Ili
tI_Z' ;;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 Instailation Diagram: System Installed by -c�n�,` n.t�w:
if
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 thesystem will function -
satisfactorily for any given period��of time. �'
.= DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
�1 SOIL/SITE EVALUATION /
Name „ -�C�� Date
Address Lot Size
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position S S S S
P� PS PS PS
U U U
2) Soil Texture (12-36 in.) Sandy, S S S
Loamy, Clayey, (note 2:1 Clay) ct5 PS PS PS
U U U U
3) Soil Structure (12-36 in.) S S S
Clayey Soils PS PS PS
U U U U
4) Soil Depth (inches) S S S
PS PS PS PS
U U U
5) Soil Drainage: Internal S S S
PS PS PS PS
U U U
External S S S
?Vs
PS PS PS
U U U
6) Restrictive Horizons
7) Available Space S S S
is 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 � l/ Title Date
SITE DIAGRAM
DCHD(6-82)
S ti.
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT F*'
Davie County Health Department
Environmental Health Section
R 0. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
"Home Phone
`�/1. Permit Requested By Business Phone
2. Address
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.
bj
5. System used to serve what type facility: House Mobile Home-2L'-Business
Industry Other
b) Number of people 2
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions
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 showers washing machine
dishwasher sinks
8. a) Type water supply: Public L" Private Community
b) Has the water supply system been approved? Yes ✓No
9. a) Property Dimensions ( . + c3,C_y-e
b) Land area designated to building site `3
c) Sewage Disposal Contractor
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.
a - 3 C) 1
Date J Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
It
r. .
!/L v ^
DCHD(6-82)
{ P�0
k J
. Pp
'y O
DAVID HART
MIRANDA ANN HART.
\ // DEED BOOK 113 PAGE 314 3
ss2' `°
RR E• 59 9,
IRON PIP S640430 "E Qom: a ca
ooa a \a9 a 334.32`� 374•QQ• X. I 0 h
O
RR SP/K� 19.6A O�
/VJ3o � Q7
l' ON
RO
U ;
0)
h
0
\ tib a o
f m
U
m (oti
Ar ti �-
/ S) m v 3'
r ' �O`ROD N
o +�
QQ P,ao ° Q OrtOQ- �
,
29 1
O 2.12.
16
T '
ler q
o
w 3
� O
�- IROR RDD 0�
,
o ;
DEED°pDQe 2 PUCCJ NSBo'Q'QO.. h
.
PAGE3sM \ w JQr Po 1
/RON p/pE
DEED goo 3 ros'C J
\ \ A GE 333
r Y- •
SEAL -
0 100 200 300
.:c':: L-1761
'C:t=•�:^Sll:.��.:� ;� FWBACKTITLE
MAP
S L.WILLIAMS - MARY H .
•TOWNSHIP• -COUNTY- -STATE- •DATE-
JERUSALEM DAVIE N. C. 12-21-85
"1,CERTIFY THAT ON ` �'� - 2.865 ACRES TRACT GEEDBOOK 97, PAGE 205
1f 8-9 , WE SURVEYED THE PROPERTY SHOWN ON3. 156 ACRES TRACT DEEDBOOK III, PAGE 303
THIS PLAT, , FRANCIS B.GREENE �o•No.
o SURVEYING AND MAPPING CO.
rMAPPlDc P.O.BOX 501 MOCKSVILLIE,N.C.27020 N-6- 68
..... ..... .... .. . .