191 Myers Rd ! DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION 1f
*NOTE:Issued in Compliance With Article 11 of G.S.Chapter 130a
Sanitary Sewage-Systems �1V"de Permit Number
.Name -� � �Irt►.`i rte. "J j"- ��o? Kr�l�?3�— Date i� N2 5 Q 4 2
Location �� '' 1/} / P� D`"% �f fel. M,
Subdivision Name Lot No. Sec. or Block No.
Lot Size 'I � -,� — House Mobile Home 1f' Business Speculation
No. Bedrooms --No�._Baths No. in Family�—
Garbage Disposal YES ❑ NO p�- Specifications for System:
Auto Pish Washer YES W NO F-1 /� v �%' .�� �'–'epaf�s.-
Auto Wash Machine YES NO ❑
Type Water Supply
*This permit Void if sewage system described below is not installed within 5 years from date of issue.
This permit is subject to revocation if site plans or the intended use change.
r
u /
Improvements permit by �f� /
'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
Certificate of Completion ` s 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
Davie County Health Department
Environmental Health Section
P. 0. sox 665 R�CEIVEp
Mockoville, NC 27028 BAR ,2
1 . Application/Permit Requested By Tr-
Mailing
omMailing Address RT. 3 2 YIorkS V.
Home Phone cl 3 Business Phone
2. Name on Permit if Different than Above S-q�l'Y«
3. Property Owner if Different than Above ,fRJner
4. Aication/Permit For: Teneral Evaluation 9111 Tank Installation
5. System to Serve: [j House TKIM—obile Home Q Business
0 Industry u Other 0 Unknown
6. If house, mobile home: Subdivision Sec. Lots
No. of People Dwelling Dimensions
No. of Bedrooms /� Basement/Plumbing
No. of Bathrooms y `basement/No Plumbing
(Washing Machine E//95 �e r Dishwasher 0 Garbage Disposai
7. If business, industry, other: Specify type
No. of People Served No. of Sinks
No. of Commodes No. of Urinals
No. of Lavatories No. of Water Coolers
No. of Showers
8. Type of water supply: @-�ublic 0 Private D Community
9. Property Dimensions _ J2, 47C-e_.
10. Sewage Disposal Contractor
11 . Do you anticipate additions/expansions of the facility this system is
intended to serve? 0 Yes L"0
If yes, what type?
*NOTE: Improvements Permits shall be valid for a period of 5
years from date issued. Improvements Permits are subject
to revocation, if site plans or the intended use change.
Effective October 1, 1989.
This is to certify that the information provided is correct to the
best of my knowledge, and I understand I am responsible for all
charges incurred from this application.
Date V Signat re
Directions to Property : 77�� ff i
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DCHD (10-89)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section.
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
// .
Name Date
Address Lot Size
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position S S S
U
2) Soil Texture (12-36 in.) Sandy, (!P
Loamy, Clayey, (note 2:1 Clay)
U U U U
3) Soil Structure (12-36 in.) �,��� S S S S
Clayey Soils �' d d i9
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
ExternalS
P --US
6) Restrictive Horizons
e )
7) Available Space ®
PS PS PS PS
U U U U
8) Other (Specify) ��� ) ® av�' (V w
PS PS PS PS
U U U U
9) Site Classification
U—UNSUITABLE S—
SUUITAB/LE PS—Provisionally Suitable
Recommendati ns/Com ent : S�� ���� ���' K-�n ' =f J�'011 x`l�%��y� ^✓v �'�h-
Described by �� Title -, n - --- Date f�
SITE DIAGRAM
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vy
DCHD(6-82)
Davie County Aealti D artment
and Nome Nealti yency
210 HOSPITAL STREET I P.O. BOX 665
MOCKSVILLE.N.C. 27028
PHONE:(704)634.5985
April 16, 1990
- James K. Smith, Jr.
Rt. 2, Box 337
Mocksville, NC 27028
Re: Site Evaluation & Permit 5942
Myers Road
Dear Mr. Smith:
Please find enclosed your permit for the installation of a septic tank
system requested on a site on Myers Road.
Please note that this system contains several variations from the
conventional system. A Bull Run valve must be installed between the two sets
of drainfield. This will enable the homeowner to easily switch from one field
to another should a problem occur. Secondly, the lines must be backfilled with
a sandy loam or sand backfill to ensure greater evaporation.
If you have any questions regarding this system, feel free to call.
Sincerely,
Robert B.. Hall, Jr. , R.S.
Environmental Health Section
RH/wd
Enclosures