222 Lakewood Dr \ f
F
NTY HEALTH DEPARTMENTIMPROVEME IT AND CERTIFICATE OF COMPLETION
i TOTE Issued in Compliance with G. f North.Carolina Chapter 130 Article 13c
Sewage Treatment and Disposal Rules (10 NCAC 10A .1934-.1968) Permit Number
%� .. i '♦ ,
Name y.1 .�� c_ ;/ir�•r�J Date
Location ( � S /'r .,re;.;�i r,��/ /f�;� 4� ✓i: . �7 r�: ,�- �:� #
Subdivision Name Lot No. Sec. or Block No.
Lot Size ouse Mobile Home _v. . Business Speculation
No. Bedrooms No. I�ths ^ _ No. in Family _
Garbage Disposal YES ❑ NO Z-'- Specifications for System:
Auto Dish Washer YES NO -❑
Auto Wash Machine YES NO ❑ fti��..✓� �fi '�;),��,� :;
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: System Installed by RRNa (YN"I
' _ ��1 S �}
Lit%
54 04
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1
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.
3 wY Fs
DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
rNOTE� Issued in Compliance with G'6., f North Carolina Chapter 130 Article 13c
Sewage Treatment and Disposal-Rules (10 NCAC 10A .1934-.1968) Permit Number
`'
Name Date � 1,•�, j`, 6� M 111
Location
Subdivision Name Lot No. Sec. or Block No.
Lot Size -=% House Mobile Home _�%" Business -- Speculation
No. Bedrooms No. Baths —`� No. in Family _
Garbage Disposal YES ❑ NO Specifications for System:
Auto Dish Washer YES NO ❑ :. _
Auto Wash Machine YES j NO ❑ r `"
Type Water Supply —/
*This permit Void if sewage system described below is not installed within 36 months from date of issue.
t
T
i
j
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: System Installed by N-0 (YN',t Ice
i
Certificate of Completion t��' 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.
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT ��?5
Davie County Health Department t
Environmental Health Section
R O. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
SUE i�.
Home Phone SON
1. Permit Requested By Business Phone
2. Address O V30 �
3. Property Owner if Different than Above
Address O%
4. Permit To: a) Install Alter Repair
b) Privy Conventional Other Type
Ground Absorption ed
c) Sub-Division\ �ra Sec i ' L Lot N .V)
5. System used to serve what type facility: House Mobile Home Business
IndustryOther
b) Number of people 1
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions X 1 O
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 Private—Community-
b) Has the water supply system bygnen approved? Yes No
9. a) Property Dimensions lcxC
b) Land area designated to building site
c) Sewage Disposal Contractor f LStL:� ��1rYKo'Y�
10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve?
What type? - 1\7l
This is to certify that the information is correct to the best of my knowledge.
25 Fes ) ) ,�
. �
Date Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
o�
DCHD(6-82)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION �y
Name %`/ Date �(1�
Address Lot Size w
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position S SS S S
a5 � PS
2) Soil Texture (12-36 in.) Sandy, S S S S
Loamy, Clayey, (note 2:1 Clay) PS PS PS PS
U UU U
3) Soil Structure (12-36 in.) S S S S
Clayey Soils PS PS PS PS
U U U U
4) Soil Depth (inches) S S S S
PS PS PS PS
U U U U
5) Soil Drainage: Internal S S S S
PS PS PS PS
U U U U
External S S S S
PS PS PS PS
U U U U
6) Restrictive Horizons
7) Available Space 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
U—UNSUIT S—SUITABLE PS—Provisionally Suitable
Recommendations/Comments:
Described by Title ! h/ Date
SITE DIAGRAM
u 01
DCHD(6-82)
•NORTH CAROLINA
DAVIE COUNTY
THIS DEED OF EASEMENT made and executed this day of November,
1985 by and between KENNETH SPILLMAN and his wife, DEBBIE SPILLMAN parties
of the first part and MIKEY W. O'BRIEN and wife, GINA H. O'BRIEN parties
of the second part:
W I T N E S S E T H :
THAT FOR AND IN CONSIDERATION of the sum of Ten ($10.00) Dollars
in hand paid and other good and valuable considerations, parties of the
first part for themselves, their heirs and assigns do hereby give and
grant unto parties of the second part their heirs and assigns a perpetual
easement to place and maintain a. sewerage outfall septic line upon the
following described premises:
BEGINNING at an iron pin, Southwest corner of that .459
acre tract described by Deed recorded in DB 128, page 568
Davie County Registry and running thence North 80 degs. 39
min. 51 sec. West 70 feet to a point; thence North 04 degs.
07 min. 09 sec. Ea.st 70 feet to a. point; thence South 80
degs. 39 min. 51 sec. East 70 feet to a point in the line
of said .459 acre tract; thence with the line of said tract
South 04 degs. 07 min. 09 sec. West 70 feet to the POINT
AND PLACE OF BEGINNING.
TO HAVE AND TO HOLD THE AFORESAID EASEMENT to them the said parties
of the second part and their heirs and assigns it being understood and
agreed that the said easement is appurtenant to said .459 acre tract
described by deed book 128, page 568 and runs with the same in the hands
of all persons whomsoever.
IN TESTIMONY WHEREOF the aforesaid KENNETH SPILLMAN and wife, DEBBIE
SPILLMAN have hereunto set their hands and affixed their seals to this
deed of easement this the day and year first above written.
(SEAL)
(SEAL)
i1N AND VAN HOY
?ORNEYS AT LAW
iOCKSVILLE,N. C.
r
f.
r
NORTH CAROLINA, County.
I, a Notary Public of the County and State aforesaid, certify that
KENNETH SPILLMAN and wife, DEBBIE SPILLMAN, parties of the first part,
personally appeared before me this day and acknowledged the execution
of the foregoing deed of easement.
Witness my hand and official stamp or seal, this _� day. of November,
1985.
My commission expires:
Notary Public
r
MARTIN AND VAN HOY
ATTORNEYS AT LAW
MOCKSVILLE, N.C.