104 Cockerham Ln 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
Namer>��' �,,_ic,�.J DateSLS
• �PS
Location ,,i.� /i l7 �.;�,.>! �f i'— i �'/ �!�r f �. r! : ;/ ctA -1%1,
Subdivision Name Lot No. Sec. or Block No.
Lot Size House Mobile Home _s Business __ Speculation
No. Bedrooms —_ No. Baths L No. in Family a _
Garbage Disposal YES p NO []., Specifications for System: 10'30
�-
Auto Dish Washer YES NO
Auto Wash Machine YES NO
Type Water Supply Wea.. _— ijo r.[�,
*This permit Void if sewage system described below is not.installed within 36 months from date of issue.
f
I
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Improvements permit by Y11�tti
*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 b /u��t
1
X
. 3
Certificate of Completio `� �% Date —
*The signing of this certificate shall indicate that the system descri ed 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.
a
LEGEND
EIP=EXISTING IRON PIN
NIP=NEW IRON PIN
* =RAILROAD SPIKE IN
O = NAIL IN ROAD
� VO
W
Q
PAUL COCKERHAM CpCKERNAM`
DB. 54 PG. 340NVEYEp TO ?AVl' C. 18.51 EIP -
8E CO � NIP
N 45 34 37"E S Tp ° 04" E �' S 230 08' 03" E
2616 30' 78 13 A 0
% �� 23y2o 0 f 24" S 89° 03' 43" E -+ N A012 AREA= 0.437 ACRE
0°) HICKORY NIP NIP 43Q86
P°� 1x2 AREA 45}ACRE in 166,80 3 S 89° 03' 43' E -- 52x.06 EIP
(INCLUDES S.R:1605 R/W) o N2P�rE
v ^ CLYDE ALLEN
_ D.B. 45 PG, 5
FOUNDAXLE 3161$ N o° -
N 76° S - o ^ AREA = 2.679 ACRES
40 W NIP 16j42 v>
32.04 O
�0 NIP _
!y N 78.3 4, 5gh W
t
1136.15 TOTAL 6S2.5S
LLOYD ALLEN EIP
D.B. 63 PG. 388
I
TOLERANCES REVISIONS SURVEY FOR
,,.•� ' " , •�, ([XCpT As Norcol NO. DATE 6Y PAUL C COCKERHAM
rQ� GIST '; 1.GRMW L TUTTEROW, CERTIFY THAT UNDER C.
• t MY DIRECTKkJ AND SUPERVISION,THIS MAP DECIMAL I BEING 3 TRACTS OF THE PAUL CLIFTON
2 SEAL WAS DR aW14 FROM .AN ACTUAL FIELD SURVEY ± COCKERHAM PROPERTY(QB. 76 PG.616,D,B.101 PG.
s 207).LYING IN MOCKSVILLE TWSP. DAVIE CO., N.C;
L Z5Z7 i MADE 6Y TUITEROW SURVEYING CO. FRACTIONAL
K DRAWN BY SCALE, '
MMATERIAL
y TLROW SURVEYIMG CID. ±
••� SUi��`g �� - CHK'D DJC DATE 1-100 DRAWING NO.
�Q ��I!� . ROUTE 6 BOX 129 F4
ANGULAR GLT 6-17-83
! ~ �`� REGI AED SURVEYOR L 2527 1i1AOCKSVI TRACED APr'D 10283-2
1,��1TV ��• LLE. N. C. 4%-3616 + S
�� no.naanxl� 1 t
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department .01
Environmental Health Section `
P. O. Box 665 rJ
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone 1-ha - 7397
1. Permit Requested By ��° �y - L so Business Phone
2. Address ��`'r�- �r ��\ AA mnGKsv, 1\� NG 8-�0
3. Property Owner if Different than Above
Address
4. Permit Td: a) lnstall�.Z 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-AZ Business
IndustryOther
b) Number of people a
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions
Bed Rooms � Bath Rooms a- 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 a- urinals 0 garbage disposal
lavatorya— showers (2- washing machine
dishwasher / sinks
8. a) Type water supply: Public Private \Z Community
b) Has the water supply system been approved? Yeses No
9. a) Property Dimensions
b) Land area designated to building site
c) Sewage Disposal Contractor aL' Sete,c
10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve? No
What type?
This is to certify that the information is correct to the best of knowledge.
Date Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
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oma--j2errJ�
DCHD(6-82)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. 0. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name F��^�l1 /�o7J�
Date
i
Address Lot Size
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position eP <1P S S
PS PS PS PS
U U U U
2) Soil Texture (12-36 in.) Sandy, S S S S
Loamy, Clayey, (note 2:1 Clay) ® PS PS
U U U U
3) Soil Structure (12-36 in.) S S S S
Clayey Soils C57 S> PS PS
U U U U
4) Soil Depth (inches) S
SS S
PS PS
U U U U
5) Soil Drainage: Internal S S S S
PS PS
U U U U
External S S S S
PS PS
U U
6) Restrictive Horizons
7) Available Space S
. S S
PS PS
U U U U
8) Other (Specify) S S S S
PS PS PS PS
U U U U
9) Site Classification J f
U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable
Recommendations/Comments: b�lta��w'J-5 f�
Described by Title • Date
SITE DIAGRAM
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DCHD(6-82)