137 Mockingbird Lot 112-114DAVIE COUNTYi•HEALTH DEPARTMENT
• ' (Septic, Tank) Improvements Permit
and Certificate of C on
(Ground Absorption Sewage•Disposal ,System - G.S. Chapter 130-Article 13C').
.OWNER OR CONTRACTOR ks : t1 . ` . 1 t ; ,
DATE' `Ia1 ^- '" PERMIT
.'LOCATION. •.(f,..c�
P� NO U
76"
S.R. NO.
.SUBDIVISION NAME y u; LOT N0. SECTION OR BLOCK N0.
,1
i!
HOUSE ( MOBILE HOME: E3 BUSINESS ❑
' .House
Tral ler • 800 Gal."400 Sq. Ft.
N0. BEDROOMS.. N0. BATHROOMS
Two Bedroom House 800 Gal. 600 Sq: Ft.
GARBAGE DISPOSAL UNIT '' YES ❑ NO ❑
Three BedroomHouse 900 Gal. 900 Sq. 'Ft.
AUTO. DISHWASHER." YES" ❑ '"NO ❑
Four Bedroom House. 1000 Gal.. 12:00 Sq., Ft.
-AUTO. WASH. MACHINE ' • YES ',;.❑ NO
�•
++�'o �. o� _ ei: � � '�''�► _.
SITE SUITABLE.. YES,. [3 NO ❑
SIZE OF TANKgal.
�� �' ~' �.
vim• � � ►., S:.n �. �\a:t � :
NITRIFICATION FIELD pi sq.' ft.
DEPTH OF. STONE IN LINES s
-
ISI • '
i.,
•WATER SUPPLY: Individual 0 Public
IMPROVEMENTS PERMIT BY ,;,,;
INSTALLED BY 74—
CERTIFICATE OF COMPLETION'.
' BYbate'
(8/"16/73) *'Construction must ply with all
other applicable State.and local.-'regulations
LOT . AREA
DAVIE COUNTYi•HEALTH DEPARTMENT
• ' (Septic, Tank) Improvements Permit
and Certificate of C on
(Ground Absorption Sewage•Disposal ,System - G.S. Chapter 130-Article 13C').
.OWNER OR CONTRACTOR ks : t1 . ` . 1 t ; ,
DATE' `Ia1 ^- '" PERMIT
.'LOCATION. •.(f,..c�
P� NO U
76"
S.R. NO.
.SUBDIVISION NAME y u; LOT N0. SECTION OR BLOCK N0.
,1
i!
HOUSE ( MOBILE HOME: E3 BUSINESS ❑
' .House
Tral ler • 800 Gal."400 Sq. Ft.
N0. BEDROOMS.. N0. BATHROOMS
Two Bedroom House 800 Gal. 600 Sq: Ft.
GARBAGE DISPOSAL UNIT '' YES ❑ NO ❑
Three BedroomHouse 900 Gal. 900 Sq. 'Ft.
AUTO. DISHWASHER." YES" ❑ '"NO ❑
Four Bedroom House. 1000 Gal.. 12:00 Sq., Ft.
-AUTO. WASH. MACHINE ' • YES ',;.❑ NO
�•
++�'o �. o� _ ei: � � '�''�► _.
SITE SUITABLE.. YES,. [3 NO ❑
SIZE OF TANKgal.
�� �' ~' �.
vim• � � ►., S:.n �. �\a:t � :
NITRIFICATION FIELD pi sq.' ft.
DEPTH OF. STONE IN LINES s
-
ISI • '
i.,
•WATER SUPPLY: Individual 0 Public
IMPROVEMENTS PERMIT BY ,;,,;
INSTALLED BY 74—
CERTIFICATE OF COMPLETION'.
' BYbate'
(8/"16/73) *'Construction must ply with all
other applicable State.and local.-'regulations
LOT . AREA
DAVIE COUNTYi•HEALTH DEPARTMENT
• ' (Septic, Tank) Improvements Permit
and Certificate of C on
(Ground Absorption Sewage•Disposal ,System - G.S. Chapter 130-Article 13C').
.OWNER OR CONTRACTOR ks : t1 . ` . 1 t ; ,
DATE' `Ia1 ^- '" PERMIT
.'LOCATION. •.(f,..c�
P� NO U
76"
S.R. NO.
.SUBDIVISION NAME y u; LOT N0. SECTION OR BLOCK N0.
,1
i!
HOUSE ( MOBILE HOME: E3 BUSINESS ❑
' .House
Tral ler • 800 Gal."400 Sq. Ft.
N0. BEDROOMS.. N0. BATHROOMS
Two Bedroom House 800 Gal. 600 Sq: Ft.
GARBAGE DISPOSAL UNIT '' YES ❑ NO ❑
Three BedroomHouse 900 Gal. 900 Sq. 'Ft.
AUTO. DISHWASHER." YES" ❑ '"NO ❑
Four Bedroom House. 1000 Gal.. 12:00 Sq., Ft.
-AUTO. WASH. MACHINE ' • YES ',;.❑ NO
�•
++�'o �. o� _ ei: � � '�''�► _.
SITE SUITABLE.. YES,. [3 NO ❑
SIZE OF TANKgal.
�� �' ~' �.
vim• � � ►., S:.n �. �\a:t � :
NITRIFICATION FIELD pi sq.' ft.
DEPTH OF. STONE IN LINES s
-
ISI • '
i.,
•WATER SUPPLY: Individual 0 Public
IMPROVEMENTS PERMIT BY ,;,,;
INSTALLED BY 74—
CERTIFICATE OF COMPLETION'.
' BYbate'
(8/"16/73) *'Construction must ply with all
other applicable State.and local.-'regulations
LOT . AREA
APPLICATION FOR SITE EVALUATION/ IMPROVEMENTS. PERMIT
Davie County Health Department
�00 Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone (-,, 9 q — S 50
1. Permit Requested By Business Phone (4
2. Address �2 TZ bo rn
3. Property Owner if Different than Above _
Address
4. Permit To: a) InstallyAlter Repair
b) Privy Conventional/ Other Type
Ground Absorption ,,_C d OV -1i _IX y 4c`� r
c) Sub -Division a' G-�— Sec. Lot No. Or q 1,C/ 2 9�
5. System used to serve what type facility: House v Mobile Home Business M4 f
Industry Other—
b)
ther b) Number of people
6. a7 If house or mobile home, state size of home and number of rooms.
House Dimensions a 8 )( `4
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 hou
7. Number and type of water -using fixtures:
commodes o2 urinals garbage disposal IV a
lavatory o2 showers washing machine
dishwasher sinks
8. a) Type water supply: Public v Private Community
b) Has the water supply system been approved? Yes I No
9. a) Property Dimensions � • O 7
b) Land area designated to building site
c) Sewage Disposal Contractor d6-& &JtJ !V2-
10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve? IZ1 Q
What type?
This is to certify that the information is correct to the best of my knowledge.
Date Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
' *NOTE: Improvements Permits shall be valid for a period of 5
years from date issued. Improvements Permits are subject
to revocation, if site plans or the intended use change.
Effective October 1, 1989.
DCHD (6-62)
r
Name—
Address
FAr.Tnac
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section.
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Date = 2�1/,
Lot Size / tAC
ARFA 1 ARFA ? AREA 3 ARFA 4
1) Topography/ Landscape Position
S�
S
P
S
(6)
U
U
U
2) Soil Texture (12-36 in.) Sandy,
Loamy, Clayey, (note 2:1 Clay)
( P�
'�j
S
�
S
U
S
U
3) Soil Structure (12-36 in.)
Clayey Soils
S
S
(5)PS
PS
S
U
U
U
4) Soil Depth (inches)
<T�-
di)
�
SS
U
5) Soil Drainage: InternalC.5
®
�
S
U
U
U
External
P
�
—6
P
U
U
U
U
3) Restrictive Horizons
7) Available Space
SS
t�
S
('
�j
S
U
U
3) Other (Specify)
S
PS
S
PS
S
PS
S
U
U
U
3) Site Classification
pD
dS
ipf
jt
v
U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable
Recommendations/Comments:
Described by
Date
SITE DIAGRAM
UCHD (6-82)