415 Peter Hairston Rd DAVIE COUNTY HEALTH DEPARTMENT
(Septic Tank) Improvements Permit and Certificate of Completion
(Ground Absorpt.Ltm Pewaize D spt>ra1 Sys em - G.S. Chapter 130-Article 13C)
OWNER OR CONTRACTOR // /�rJe.: DATE PERMIT
LOCATIONdt/CJ4?/j7& !� 1 F 1.&"e% �- �' f� « l� 1
S.R. NO.
SUBDIVISION NAME LOT NO. SECTION OR BLOCK NO.
HOUSE MOBILE HOME BUSINESS ❑
House Trailer 800 Gal. 400 Sq. Ft.
NO. BEDROOMS _ N0. BATHROOMS Two Bedroom House 800 Gal. 600 Sq. Ft.
GARBAGE DISPOSAL UNIT YES ❑ NO ❑ Three Bedroom House. 900 Gal. 900 Sq. Ft.
AUTO. DISHWASHER YES ❑ NO ❑ Four Bedroom House 1000 Gal. 1200 Sq. Ft.
AUTO. WASH. MACHINE YES ❑ NO ❑
SITE SUITABLE YES ❑ NO ❑
SIZE OF TANK _ 2400 gal.
NITRIFICATION FIELD 4 0(0 sq. ft.
DEPTH OF STONE IN LINES: _ ,,....,,► //^
WATER SUPPLY Individual LT"Public ❑
IMPROVEMENTS PERMIT BY INSTALLED BY
CERTIFICATE OF COMPLETION By Date
(8/16/73) *Construction must comply with all other applicable State and local regulations
LOT AREA
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DAVIE COUNTY HEALTH DEPARTMENT
(Septic Tank) Improvements Permit and Certificate of Completion
(Ground AbsorptUn Sewage Disposal System - G.S. Chapter 130-Article 13C)
OWNER OR CONTRACTOR ""r' { }� 't'/ ,+`j �, �-;;/'o L. DATE PERMIT
LOCATION Ljb/i2 C P'�r r+ it f c3� --» I`1c�/ . c7 ? .LY •
S.R. NO.
SUBDIVISION NAME LOT NO. SECTION OR BLOCK NO.
HOUSE MOBILE HOME BUSINESS ❑
House Trailer 800 Gal. 400 Sq. Ft.
NO. BEDROOMS NO. BATHROOMS Two Bedroom House 800 Gal. 600 Sq. Ft.
GARBAGE DISPOSAL UNIT YES ❑ NO ❑ Three Bedroom House 900 Gal. 900 Sq. Ft.
AUTO. DISHWASHER YES ❑ NO ❑ Four Bedroom House 1000 Gal. 1200 Sq. Ft.
AUTO. WASH. MACHINE YES ❑ NO ❑
SITE SUITABLE YES ❑ NO ❑
SIZE OF TANK A A gal.
NITRIFICATION FIELD C3 0 sq.' ft.
DEPTH OF STONE .IN LINES:, .►'�
WATER SUPPLY: Individual 2§�--Public ❑
IMPROVEMENTS PERMIT BY INSTALLED BY
CERTIFICATE OF COMPLETION By Date
(8/16/73) *Construction must comply with all other applicable State and local regulations
LOT AREA
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ryy 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 ,��r 1; k� e, { Date3992
Location
Subdivision Name Lot No. Se-c. or Block No.
Lot Size House Mobile Home _ Business _IG Speculation
No. Bedrooms No. Baths —Z No. in Family —
Garbage Disposal YES p NO ❑ Specifications for System;__, ,
Auto Dish Washer YES ❑ NO ❑ r` " -4' ;% ':_'
Auto Wash Machine YES E) NO p
Type Water Supply '
"This permit Void if sewage system described below is not installed within 36 months from date of issue.
� n
�l
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 byp��
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.
•' ' ' DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
R 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 S
PS PS PS
U U U U
2) Soil Texture (12-36 in.) Sandy, S S S
Loamy, Clayey, (note 2:1 Clay) PS PS PS
U U U
3) Soil Structure (12-36 in.) S S S S
Clayey Soils � PS PS PS
U U U
4) Soil Depth (inches) S S S
PS PS PS PS
U U U
5) Soil Drainage: Internal S S S S
" ff PS PS PS
U U U U
External S S S
PS' PS PS
U U U
6) Restrictive Horizons
7) Available Space 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—UNSUITABLE S—SUITABLE PS—Provisionally Suitable
Recommendations/Comments:
Described by '� �/ Title �� Date
,SITE DIAGRAM
DCHD(6-82)
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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 �r T•�k'. -�/ I RS t�N I. �` K 3�L/_ Date 2�45 6'C
6„a, Jry.�.�J
nn /EjttPit c`� tic..
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: 15-00
Auto Dish Washer YES NO ❑ i /4
Auto Wash Machine YES NO ❑ 3 Y. _3
Type.Water Supply
*This permit Void if sewage system described below is not 'nstalled within 36 months from date of issue.
IN
Improvements permit byr '
*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: Syster i Installed by
(0
Certificate of CompletiDate
'The signing of this certificate shall indicate that the system des c 'be above has been stalled in compliance with
the standards set forth in the above regulation, but shall in NO way ken as a guarante that the system will function
satisfactorily for any given period of time.
4 _. -.._. - •+v4-. i .. .., ., w.. A-: wa .t - a a•A.'.. .,vim s'('-.t. _. r.J.... - .. _ .. .. e.. . a.... _.r ..-. � i . ..-.
~� DAVIE COUNTY HEALTH DEPARTMENT
_ y 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 t' ,r7... 41\1 ISTom J. i.�K 3 1/ �I t. .. �, t
Date
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 Dish Washer YES NO ❑ < r ii
Auto Wash Machine, YES [ NO ❑ :3 Y. .3 K
Type Water Supply U,J� _--`
*This permit Void if sewage system described below is not 'nstalled within 36 months from date of issue.
Improvements permit
*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 Completi n-�"`�'"` Date- yy
*The signing of this certificate shall indicate that the system describe above has been n
9 9 y + s e stalled in compliance with
the standards set forth in the above regulation, but shall in NO way be•t ken as a guarante that the system will function
satisfactorily for any given period of time.