P4813 Milling Rd .ay,_..ra..++c*y.t.w'L• -v,•.. . .. •iru,.+..r«s....,. .. .. _,. _ .
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 / ���rY . .� � �'�'%"--- %�Date � r�ZZ
Location �•' /. r' I'/� - -_ y / 3: .r' �� i ri':.:P
Subdivision Name Lot No. - Sec. or Block No.
Lot Size _--- House L 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 NO
Type Water Supply __—
"This permit Void if sewage syste�n described below is not installed within 36 months from date of issue.
Aj
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. Telephonedlumber: 704-634-5985.
Final Installation Diagram: System Instal by
!J'
r
/ice/
Certificate of Completion _ �C%. _ 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.
Ir APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
f Davie County Health Department ���
Environmental Health Section
P. O. Box 665 ��Cr
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
T Home Phone 9
, 19-
1. Permit Re sted By ' . 4pv Business Phone
2. Address U45ow 3 �,4 / r 614 2 7&Z 7-
3.
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: HouseM�ome Business
Industry Other
b) Number of people
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions 49 X SO
Bed Rooms Bath Rooms Y Den w/Closet �o
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 7- urinals A/O garbage disposal �a
lavatory y showers Y 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 I Sk x LU X 77' /1X 2-S-0,-S�
b) Land area designated to building site
C) Sewage Disposal Contractor N07 ,Vo w t l
10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve? d
What type?
This is to certify that the information is correct to the best of my kn wledge.
Date 7 Ow er Sign ture
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property: �^
Tun tj DNi o 1 • �I-nJ� ICD Dry I j e =�T - 10 / PAX
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DCHD(6-82)
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r DAVIE COUNTY HEALTH DEPARTMENT
Y Environmental Health Section
P. 0. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name X� Date &)K7
_
Address Lot Size -
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position S S S
< SD AP PS PS
Z�jjU U
2) Soil Texture (12-36 in.) Sandy, S S
Loamy, Clayey, (note 2:1 Clay) S PS PS
U U
3) Soil Structure (12-36 in.) S S
Clayey Soils PS PS
U U U
4) Soil Depth (inches) S S
S C.11/ PS PS
U U
5) Soil Drainage: Internal _ S S
P PS PS
`tT U U
External �S–�� /l,�ri S S
l'FSS PS
U
6) Restrictive Horizons
7) Available Space S S S
PSS PS PS
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 Title Title Dateg
SITE DIAGRAM
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DCHD(6-82)
Davie County Aealt!i De artment
and dome Nealt§ Aen
9 cy
210 HOSPITAL STREET/P.O. BOX 665
MOCKSVILLE, N.C. 27028
PHONE:(704)634-5985
March 14, 1988
Tommy Anthony
P. 0. Box 834
Clemmons, NC 27012
Re: Sewage System Installation
Milling Road
Dear Mr. Anthony:
The septic tank system that serves this residence was designed,
inspected and approved by this office on August 3, 1987.
With proper maintenance and use it should function properly.
Sincerely,
't�� �-
Robert B. Hall, Jr., R.S.
Environmental Health
RH/wd