844 Wagner Rd DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*Note:.lssued in Compliance with G.S. of North Carolina Chapter 130—Article 13c.
Permit Number
Name �r;,, 1 rte. .11 - Date !vv- t C1 .19
Location
!, 11' ! ) {b il.lrl e r�l r1. Lam' 1-7
- - -
Subdivision Name Lot No. Sec. or Block No.
1 r,�
Lot Size i r1r,r `1<,r,>., House Ll-- Mobile Home _ Business Speculation
No. Bedrooms 3 No. Baths ' 'I No. in Family
Garbage Disposal YES ,p NO p— Specifications for System: Cloo c" -.•� '—
Auto
-Auto Dish Washer YES p' NO
Auto Wash Machine YES p NO 0
Type Water Supply ',W !� _—
*This permit Void if sewage system described below is not installed within 36 months from date of issue.
Improvements permit by �` �� \u T\AZ
*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 `�
►so
-4D
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
P. 0. BOX 57
14OCKSVILLE, N. C. 27028
(704) 634-5985
,,Statement -for Septic Tank Improvement Permits
and/or Site Evaluations
NAME i���ut C rci „ �`,1 l DATE ISSUED 5- 1 --79
ADDRESS ���L a, ` �{ �S Y PER14IT NO. A i3l
1'�ocKs��tie.
Explanation of. charge `a•,ae
AMOUNT DUE SANITARIAN%. f-YAaw o
PLEASE RE141T THE ABOVE AMOUNT ON RECEIPT OF THIS STATEMENT.
DAVIE COUNTY HEALTH DEPARTMiT
PERCOLATION TEST RESULTS
DATE (�a 1` 1 5 1 5
NAWIE
LOCATION U3aa R e -Q- `�eon c. �e cx� F"�n1L s Q. l3 I d
FIIIDI14GS: HOLE N0. COINDIENTS
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CIA
5 �n �Lo to GL�'""�' /•70,n.'�'��•
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By:
LOT`DIAGRAIM \ QerC — \T\wCL%\ �o1es �resoa�- LR1`vu rs
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Form FHA-NC 424-2
(3-35-71) Pill
i
•UNITED STATES DEPARTMENT OF AGRICULTUINP 17 19T9
Farmers Hone Administration
pOWAR COUNTY NEAM QUI
PROPOSED INSTALLATION OF INDIVIDUAL SEWAGE-DISPOSAL ZD/OR WATER SUPPLY SYSTEM
Name of Property Owner pall gar_yAg Cranfi77
Property Address Route 2. ?focksVillep NC 27n?s
(If this property is in a development, give lot no. and block no.
Number of bedrooms proposed 3 Approximate area of lot loon square feet.
House is to be set back feet from the boundary. I propose to construct on
the above-captioned property an individual type sewage-disposal system
well .This installation Kill be constructed so as to meet all the require-
ments of the local Health Department and the State Board of Health.
WELL: Site location approved by Health Department ( I) yes ( ) no.
Type . Size of storage tank
Drilled, Driven, Bored, Dug)
Make: Type and capacity pump:
Septic system to be installed to accommodate: Garbage Grinder ( ) yea (x) no
Washing Machine yea ( ) no
Date:
Signature of PropertyOwner)
SEPTIC TANK: Working capacitygallons
NOTE: If tank has not been speci`fically''approved by the State Board of Health,
submit plans and specifications.
PERCOLATION TEST RESULTS (If considered necessary by local Health Department)
Hole No. 2_ (Minutes per inch of fall)
SUBSURFACE ABSORPTION FIELD
No. of nitrification lines,2_; total length feet; width inches;
inches;
total nitrification lines bottom area ,s/quare feet.
A representative of the X` Of Health .Department has
` inspected this site and fiffids it suitable unsuitable for the
r proposed installation.
Well Site Location Approved by Health Department, ( yea ( ) no.
Date: (Signature) Ak�. 1_146iL�/�
' (Title) CZ;Ial c
If there is arW pertinent information which the Health-Department desires to convey
9 to the reviewing officials, which is not covered above, use the_. back of this
a/ application.
7qReturn original and one copy to Farmers Home Administration County Office.