173 Ginny Lane Lot 6Subdivision Name SpKL1gJa Ie, Lot No. -46 --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 Washer YES 4, C] NO ❑ ���
Auto Wash Machine YES < , NO
Type Water Supply
*This permit Void if sewage system described below is not installed within 36 months from date of issue.
1A .
iI
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 In at on Diagram: System Installed by
f
Certificate of Completion ` Date IqQ
*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.
'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
Name
,,
% sDate �l�'i//-�
1
�3, j47
Locations
Subdivision Name SpKL1gJa Ie, Lot No. -46 --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 Washer YES 4, C] NO ❑ ���
Auto Wash Machine YES < , NO
Type Water Supply
*This permit Void if sewage system described below is not installed within 36 months from date of issue.
1A .
iI
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 In at on Diagram: System Installed by
f
Certificate of Completion ` Date IqQ
*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
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name_ � > Date &J/tJ
Address Lot Size
FACTr1RS APPA I ARFA 9 ARFA 3 ARFA A
Topography/ Landscape Position
e
8)
9)
S
S
S
S
PS
PS
PS
U
U
U
?) Soil Texture (12-36 in.) Sandy,
S
S
S
S
Loamy, Clayey, (note 2:1 Clay)
PS
PS
PS
U
U
U
1) Soil Structure (12-36 in.)
S
S
S
Clayey Soils
pS
PS
PS
PS
U
U
U
Soil Depth (inches)
S
S
S
PS.
PS
PS
U
U
U
) Soil Drainage: Internal.
S
S
S
pg
PS
PS
PS
U
U
U
External
S
S
S
PS
PS
PS
U
U
U
i) Restrictive Horizons
Available Space
S
S
S
PS
PS
PS
PS
U'
U
U
U
Other (Specify)
S
S
S-
S
PS
PS
PS
PS
U
U
U
Site Classification
/UU
f%� 5
U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable
Recommendations/ Comments:
1
Described by _
SITE DIAGRAM
DCHD )6.82)
Title
Date
APPLICATION FOR SITE EVALUATION/ IMPROVEMENTS PERMIT 1D�
Davie County Health Department
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone / o 7✓_ 54�w
1. Permit Re u sted By xp `
2. Address 4&0 kde�". A
3. Property Owner if Different than Above
Address
4. Permit To: a) Install ✓ Alter— Repair—
b) Privy_ Conventional Other Type—
Grou Absortion
c) Sub-Divisio P At. Sec. Lot No. (�
5. System used to serve what type fa ility: House ✓Mobile Home— Business—
Industry— Other—
b) Number of people
6. a) If house or mobile home, state size f home d panrbar of rooms.
House Dimensions
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 Z urinals
lavatory showers Z
dishwashersinks
8. a) Type water supply: Public Private Community
b) Has the water supply
9. a) Property Dimensions r/• df/ % A
b) Land area designated to building site
c) Sewage Disposal Contractor
Yes ✓ No—
garbage disposal
washing machine_
10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve?
What type?
This is to certify that the Information is correct to the bes f m ng.Wied e.
Date Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIAN WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
DCHD (6-82)
. DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
np SOIL/SITE EVALUATION.
Name l b"u-- Date
1
Address Lot Size
Fer.Tnac AREA 1 AREA 9 AREA 3 ARFA d
Topography/ Landscape Position
2)
3)
d)
5)
6)
4::T:)
S
S
S
PS
PS
PS
PS
U
U
U
U
Soil Texture (12-36 in.) Sandy,
db
S
S
S
Loamy, Clayey, (note 2:1 Clay)
PS
PS
PS
PS
U
U
U
U
Soil Structure (12-36 in.)
4::T>S
S
S
Clayey Soils
PS
PS
PS
PS
U
U
U
U
Soil Depth (inches)
C -:95S
S
S
PS
PS
PS
PS
U
U
U
U
Soil Drainage: Internal?
S
S
S
PS
PS
PS
PS
U
U
U
U
External
S
S
S
PS
PS i
PS
PS
U
U
U
U
Restrictive Horizons
)Available Space
S
S
PS
S
PS
S
PS
U
U
U
U
Other (Specify)
S
PS
S
PS
S
PS
S
PS
U
U
U
U
Site Classification
Described by
SITE DIAGRP
r
,
DCHD (6-82)
U—UNSUITABLES—SUITABL
un � s'.
Title
nally Suitable
L�cAl�
Date �-Z 'j -•r
I
i
i'
OFFICE OF THE DIRECTOR
ttuie (Qaun# ettl# a ttr#men#
ttnb Pante Peal#ll �gntrg
P. O. BOX 665
gorksUille, North (garolina 27028
June 1, 1987
TELEPHONE'
47041 634-5965
Wade Leonard
34 Town Sq.
Mocksville, NC 27028
Re: Septic Tank Instillation
Jerry Bruce Ellis/Lot 6 Springdale
Dear Mr. Leonard:
i
A representative from this office inspected the installation of this
septic system on April 21, 1987, and found it done per specifications.
Please feel free to contact this office, if we canlbe of further
assistance.
Sincerely,
Charles Little, R.S.
He
Environmental alth
CL/wd
Davie County Health Department
Environmental Health Section ,
P.O. Boz 848,
210 Hospital Street
Courier # : 09-40-06 1911
Mocksville, NC 27028
Phone: (336) - 753 - 6780 ON-SITE WASTEWATER CERTIFICATION
(Check One) Replacement Remodeling Reconnection
Fax: (336) - 753.1680
Name: "T',mPs P, Je n1ll S ;i 1PS b t �4A �A(�6 y u; 'fPhone Number 3 ✓ b �(1� �ina�U ( (Home)
� 4
Mailing Address: o ► cbL JC —7Dq — ?Id- g(y (Work)
n�t 11011.1 NL a1?IaOEmailAddreess: c4)�(�
-NoiOWfcDetailed Directions To Site: anniALrA C14 1 90
, A Sn S(oj L� C�ffCoY' �Ae(t'; ryUhp111
114 on L'VArl((n'kmeAfl
A- La�% JJ)
Property
Please Fill In The Following Information About The EXISTING Facility:
Name System Installed Under.. ' Type Of Facility:
Date System Installed (Mon Number Of Bedrooms: Number Of People:
Is The Facility Currently Vacant. ' Ye)No If Yes, For How Long?
Any Known Problems? Yes No f Yes, Explain:
Please Fill In The Following Information
About'The NFacility
UC
V0 N dig VG Slde
Type Of Facility: rda dek Nu�Ver
Of Bedrooms: Number of People
Pool Size:G
�c•• arage Size: Other:
dLRequested By: f"Ow P. Date Requested:
Signature)
For Environmental Health Office Use. Only
Approved� Disapproved
'eoaunen6..(
Environmental Health Specialist Date:
*The signing of this form by the Environmental Health Staflys in no way intended, nor should be taken as a guarantee
(extended or limited) that the on-site wastewater system will function properly for any given period'of time.
Payment: Cash Check Money Order ,# Amount:$
Paid By: Received By:
Account #: Invoice #:
I