187 Ginny Lane Lot 7o0
DAVIE COUNTY HEALTH DEPARTMENT
(`-
.',{-z' � ,• _ , IMPROVEMENTS PERMIT AND CERTIFICATE OF !COMPLETION
*-NOTE: Issued in Compliance with G.S. of North Carolina Chapter 130 Article 13c
Sewage Treatment a d Disposal5ules (10 NCAC 10A ,'1934-.1968) Permit Number
i�I Name ^7�/S/i,l ��"fZ Gl/�?i Date ,_'J4/f V-2 �.�. 4�i.�5
Location
Subdivision Name Lot No. Sec. or Block No.
Lot Size,!7e_)'�1b House ✓ Mobile Home _ Business Speculation
No. Bedrooms (No. Baths No. in Family /i_,v
Garbage Disposal NES ❑ NO p--
�. Specifications for ystem:
Auto Dish Washer YES NO ❑ //)� /�/ % / / t�fif
Auto Wash Machine YES NO •❑ / w�"
Type Water Supply
*This permit Void if sewage system descr4bed below is not installed within 36 months from date of issue
Y
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 by
S t� 0
Certificate of CompletionN. .=� _ 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.
' r c2lal
APPLICATION FOR SITE EVALUATION/ IMPROVEMENTS PERMIT
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.
1. Permit Requested By BAUD ,5 9.t% e--0 N S tg D Q Business Phone R t4 -122 - 5 18 3-
2. Address ( 1ilAa0- -c+n 01tG O+—M+,A"r-! C_ �a30
3. Property Owner if Different than Above
Address
4. Permit To: a) Install t: Alter— Repair
b) Privy— Conventional— Other Type—
Ground Absorption
c) Sub -Divisions Sec. Lot No.
5. System used to serve what type facility: House✓ Mobile Home— Business—
Industry— Other—
b) Number of people
6. a) If house or mobile home, state size of home and numberofrooms. /1
House Dimensions 2-6 x 3'S r 1 S 5 o f I A Q 1�' � 5 S�
Bed Rooms_ Bath Rooms 'Z 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 iwashing machine )
dishwasher k sinks 1
8. a) Type water supply: Public Private Community
b) Has the water supply system been approved? Yeses No -
9. a) Property Dimensions 11 S X Z'r)fl � �.; ra
b) Land area designated to building site \ 5 6 4
c) Sewage Disposal Contractor �� p r S A� 'T f
10. Do you anticipate any additions or expansions of the facility this sewage s
What type?
This is to certify that the information is correct to the best of
I, C� A,
Date
Owner
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL
AI w 5 da s fW proces ing T
Directions to property:
Amara r �Rh� It% 1e U, f-
i
DCHD )6.62)
is intended to serve? AJ i)
AND LOCAL LAWS
Address
FACTf1RA
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
ARFA I
Date
Lot Size
ARFA 9 ARFA 3 ARFA A
1) Topography/ Landscape Position
S
S
S
PS
PS
PS
U
U
U
?) Soil Texture (12-36 in.) Sandy,
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
r S
PS
PS
PS
U
U
U
Soil Depth (inches)
S
S
S
P5
PS
PS
PS
U
U
U
i) Soil Drainage: Internal
S
i
j
S
S
PS
�
,. PS
PS
U
U
U
External
/�`/>
S
I
S
S
/JU
PS
PS
PS
U.
U
U
1) Restrictive Horizons
Available Space
S
S
S
PS
PS
PS
U
U
U
1) Other (Specify)
S
S
S
S
PS
PS
PS
PS
U
U
U
U
1) Site Classification
U—UNSUITABLE
Recommendations/ Comments:
Described by
SITE DIAGRAM
"
DCHD (6.82)
S—SUITABLE PS—Provisionally Suitable
i
Title Date
Address
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
R O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Date
Lot
FAr:RY1RC ARFA 1 AREA 2 AREA 3 AREA d
Topography/ Landscape Position
zf�>
S
S
S
PS
PS
PS
PS
U
U
U
U
!) Soil Texture (12-36 in.) Sandy,
4fD
S
S
S
Loamy, Clayey, (note 2:1 Clay)
PS
PS
PS
PS
U
U
U
U
1) Soil Structure (12-36 In.)
(fg:>
S
S
S
Clayey Soils
PS
PS
PS
PS
U
U
U
U
Soil Depth (inches)
(::5>
S
S
S.
PS
PS
PS
PS
U
U
U
U
i) Soil Drainage: Internal
Z5D—
S
S
S
PS
PS
PS
PS
U
U
U
U
External
_Z:S5
S
S
S
PS
PS
PS
PS
U
U
U
U
i) Restrictive Horizons
Available Space
S
S
PS
S
PS
S
PS
U
U
U
U
3) Other (Specify)
S
S
S
S
PS
PS
PS
PS
U
U
U
U
�) Site Classification
U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable
Recommendations/ Comments:
flI 4k ,Pi,
Described by iTitle
SITE DIAGRA
zea
DCHD (6-e2)
—76—,4—,D
Date 8-2 +I
Davie Caunty Nealt/f Department
and .flame Xealtfr 9yency
210 HOSPITAL STREET / P.O. Box 665
MOCKSALLE, N.C. 27028
PHONE: (704) 634-5985
October 22, 1987
Hubbard Realty
Attn: Helen Steen
285 S. Stratford Rd.
Winston-Salem, NC 27103
Re: Sewage Disposal System
Lot 7/Gordon Drive
Springdale
Dear Ms. Steen:
On July 15, 1987, the sewage disposal system was installed at the
aforementioned location. It was inspected and met the approval of this
office at that time.
Please feel free to contact us, if we can be of further assistance.
Sincerely,
&W-Ao �3.
Robert B. Hall, Jr., R.S.
Environmental Health
RH/wd
0