159 Rex Ln _ DAVIE COUNTY. HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE bF COMPLETI N.,
*NO!fE: Issued_in Compliance with G.S. of North Carolina'Chapter 130 Article' 13c ;I
Sewage Treatment.and Disposal Rules (10 NCAC,I JOA .1934-.1968)+ Permit' Nuinber
_~^ _ NameAw
' �da�d�':�v� C � 493
Location t''�'' �i: — �' ,`✓'' r 1 !' - -ti,�t /�, `'
Subdivision Name r Lot No. Sec. or Block No.
Lot Size _4zc House Mobile Home �� Business Speculation I
No.Bedrooms.:, No. Baths No. in Family_ ;
Garbage Disposal �YES ❑ NO 1] U
Specifications for System: �y
Auto Dish Washer ' YES•❑ NO fl ` . fid'Y
Auto Wash.Machine - .YES NO ❑ "
Type 'Water'Supply - •' ' 'iJ
.1 ..
*T,his permit Void if sewage system described below is not installed within 36 months from date of issue.
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Improvements permit,by �/f
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*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.IM on day of completion. Telephone Number: 704-634��5985.
I,
Final Installation Diagram ` System Installed by /2 A�
Certificate of Completion' Zz�, . 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 as a guarantee that the system will function`
satisfactorily for any given period of time.
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT O
Davie County Health Department LO�w
Environmental Health Section G``V
P. O. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone 9 q y �4 5
1. Permit Rsted B A'_ Business Phone S
e e
2. Address e-
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: House Mobile Home Business
IndustryOther
b) Number of people -
R,
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions A X 70
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 been approved? Yeses No
9. a) Property Dimensions o 0{p P
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? n
What type?
This is to certify that the information is correct to the best of my knowledge.
N) , 5T_ / � 99 - &JI2, P0.41, ��12 ZL
Date Owe Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
! 1
Ali-
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P_na
DCHD(6-82)
•-- 'R' DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section.
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name \Q` 24 z� Date -A 1 ��
Address Lot Size `
FACTORS ARE 1 ARC)2 AREA 3 AREA 4
1) Topography/Landscape Position S S S S
PS PS
U U
2) Soil Texture (12-36 in.) Sandy, S S S S
Loamy, Clayey, (note 2:1 Clay) cEg> PS PS
U U U
3) Soil Structure (12-36 in.) S S S S
Clayey Soils P.S � PS PS
U U
4) Soil Depth (inches) S S S S
pg rP PS PS
U U U
5) Soil Drainage: Internal S S S S
PS P PS PS
Cp Vd✓ U U
External S S S
pS C9 PS PS
U U U
6) Restrictive Horizons ^) '
7) Available Space ,SSS S S
( P J PS PS
(*PD
tet! U U
8) Other (Specify) S S S S
PS PS PS PS
U U U U
9) Site Classification
U—UNSUITABLE S—SUITABLE Cps
rovisionaily Suitable
Recommendations/Comments:
�]."�►.4��n�-.,..n `^ Las.-ac.e�i � �5�+ ,.� s��._
Described by �Q . � +`" "` - Title ''� " " Date
SITE DIAGRAM
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DCHD(6-82)
_ Davie County NealtFr De artment
and .glome NealtFr 7yen
210 HOSPITAL STREET/P.O. BOX 665
MOCKSVILLE, N.C. 27028
PHONE:(704)634-5985
January 25, 1988
Douglas Rex Carter
Rt. 6, Box 96
Advance, NC 27006
Re: Off State Rd. 1453
Davie County
The on-site sewage treatment and disposal system installed at the above
mentioned location, is of such design that an Operation Permit is required
from this office. This Operation Permit is issued instead of a Certificate
of Completion. As of January 1, 1984 G.S. [130A-337(b)] requires an
Operation Permit for any system that has the following: _
Pumps and/or grease traps, any alternative system, systems
with a flow rate greater than 480 GPD, and systems serving
mobile home parks.
This Operation Permit is valid as long as the sewage treatment land
disposal system is in compliance with Article 11 of G.S. Chapter 130 A, and
all conditions imposed by the Operation Permit.
This letter shall serve as the Operation Permit for the sewage
treatment and disposal system at the above mentioned location.
��
Date of Issuance By
Title S /��i -►7