355 River Road Lot 10DAVIE COUNTY HEALTH DEPARTMENT
'(Septic Tank) Improvements Permit and Certificate of Completion
(Ground Absorption Sewage Disposal System - G.S. Chapter 130 -Article 13C)
OWNER OR CONTRACTOR..DATE PERMIT
LOCATION? z-'�:y rti• •: JR.:yl u� f-,� - ff f a 1 1�
! S. R. NO.
SUBDIVISION NAME h//, -.y/ LOT NO. to SECTION OR BLOCK NO.
HOUSE ®"'"" MOBILE HOME ❑ BUSINESS ❑
NO. .BEDROOMS
NO. BATHROOMS -•
GARBAGE DISPOSAL UNIT YES ❑ NO M`*-'
AUTO. DISHWASHER YES R-- NO ❑
AUTO. WASH. MACHINE YES Ea. NO ❑
SITE SUITABLE YES 0'. NO ❑
SIZE OF TANK 1/- , I- %
NITRIFICATION FIELD 9PrO '•a.Af"—tsq
. ft.
DEPTH OF STONE IN LINES: z? ;.#J. /P v f
WATER SUPPLY: Individual 9 --Public ❑
IMPROVEMENTS PERMIT BY tAT...t- -~•"
House Trailer 800 Gal.
Two Bedroom House 800 Gal.
Three Bedroom House 900 Gal.
Four Bedroom House 1000 Gal.
INSTALLED BY
920
400 Sq. Ft.
600 Sq. Ft.
900 Sq. Ft.
1200 Sq. Ft.
CERTIFICATE OF COMPLETION By Date
.'
(8/16/73) *Construction must compiVj ith all other applicable State and local regulations
LOT AREA
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Davie County Health Department
9,N1s f� Environmental Health Section ,
P.O. Box 848
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210 Hospital Street
Courier #: 09-40-06 1911
Mocksville, NC 27028
Phone: (336) 753 - 6780 ON-SITE WASTEWATER CERTIFICATION Fax: (336) — 753-1680
(Check One) Replacement Remodeling Reconnection
Name: L or � �) � Phone Number f)Home
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Mailing Address i > / F : ; r ) ; —t oil (Work)
Email Address: ; V i
Detailed Directions To Site: l !, r
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Property Address: U-110 -(0-007
Please Fill In The Following Information About The EXISTING Facility:
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Name System Installed Under: \ \C .� , ;1 .' Type Of Facility: r , , r 1.., 1 <` •._ , ,
Date System Installed (Month/Date/Year): i ' f i , Number Of Bedrooms: Number Of People:
Is The Facility Currently Vacant? Yes No) If Yes, For How Long?
Any Known Problems? Yes No If Yes, Explain:
Please Fill In The Following Information About The NEW Facility:
Type Of Facility: Number Of Bedrooms: Number of People
Pool Size:_
Garage Size:
Other:
Requested By: Date Requested:
(Signature)
For Environmental Health Office Use Only
►Yim�"en%s: .� �`,� .�, L '1 �`Gr' ` "/.! f � /;. ,► % !i .�J
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Environmental Health Specialist 1 Ir Date: 0/(C'/c, L y
*The signing of this form by the Environmental Health Staff is 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 # 41 L`� Amount:$_
Paid By: L6(C 16 /11 } !� � _Received By:_
Account #: -Invoice #:
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J DAVIE COUNTY. HEALTH. DEPARTMiAff
IMPROVEMENTS PERMIT,,.ANV'+.CER fi KATE OF COMPLETION
*NOTE :tissued-in.Compliance,with G.S. of North Carolina Chapter 130 Article 13c
SewaJe. Treatment and,,.Disposal Rule6'(10 NCAC 10A .1934-.1968)... Perm! umber
Namer:-:�`�iF.v, o�%Y'� Date rJL'
577
Location (4-
Subdivision Name' K)A57%iiDC3-6_, Lot No _gyp Sec: or Block No.
Lot Size -� ' Houser ` Mobile Home _ Business Speculation
No. Bedrooms ' No. Baths No. in Family
Garbage Disposal YES NO [ / )/1
Specifications for. ,Syste
Auto Dish Washer YES NO i]
Auto Wash Machine YES, NO
Type :Water $apply s! y _ ``,' '; ;';,f�';�' p, ,. p • _
*This permit Void if sewage system described below is not-installed within �Wmonths from date of issue..
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lzillImprovements permit by ZVI;
*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
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Certificate of Completion f f 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 give.n'period of time. �.
- DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTE: Issued in Compliance with G.S. of North Carolina Chapter 130 Article 13c r
Sewage Treatment and Disposal Rules (10 NCAC 10A .1934-.1968) / Permit Number
Name �� s;� � ;�'c�� %/: -' Date ���i�� N2 5775-
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Location:✓r�
Subdivision Name `1f%S"T1�� pG-E- Lot No. /0 Sec. or Block No.
Lot Size House Mobile Home _ Business __ Speculation
No. Bedrooms No. Baths No. in Family
Garbage Disposal YES NO p Specifications for System:
Auto Dish Washer YES NO p
Auto Wash Machine YES NO p �Oneetil '�/� //
Type Water Supply
*This permit Void if sewage system described below is not installed within months from date of issue.
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Improvements permit by TZ� /'/
*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
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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.
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DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS, PERMIT AND .CERTIFICATE OF COMPLETION �-
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I*PE':. .` Issued in Compliance with G.S. of North Carolina Chapter 130 Article 13c 1
w Sewage-Treatment and Di Rules (10 NCAC 10A°.193LL4-.1968) Permit Number
Name` Date -7 � t� 4,748
Location. �� �' �y:o� 1 9,1 .\I ! N �'
Subdivision Name Lot No. Sec. or. Block; No.
Lot Size V .
I 'HoyseMobile Horne --,'Bus( ness �. Speculation
No. Bedrooms 3 No. Baths No. In Family
Garbage Disposal 7YES .E] NO
,, Specifications for System:
Auto Dish Washer •YES�[�] NO i] a. t ;
.
Auto Wash-Machine. YES NO
Type' Water Supply - o U __ ~}
. *This' permit Void if sewage system described below is not installed within+36 months from date of issue.
h
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:1:00-4;30 P.M. on day of completion. Telephone Number:704-634-5985.
Final Installation Diagram: System Installed,by
a
A 1,xcl
Certificate of Completion J Date
'The ,signing of this certificate 'shall indicate that the system described above has been installed in.compl'iance 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. " ;
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IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION '\ ,
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/ ��OTE: Issued inCompliance with G.S.0f North C8n}|in8 Chapter 130 Article 13o
Sewage Treatment and Disposal Rules (10 NCAC 10A .1934-.1968) Permit Number
Name V
Date
Location
Lot No. Sec. or Block No.
Subdivision Name
^
Lot Size House ��� Mobile Home Business --- Speculation
No. Bedrooms No. Baths No. in Femi|y�_��—_--'
Garbage Disposal YES [] NO 0
Specifications for System:
Adhor
Auto Washer YES J� NO'
11
Dish /�� E]
Auto Wash Machine YES D NO F]
Type Water Supply
*This permit permit Void if nommge system described bo|ovv is not installed within 36 months from date of {aouo.
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Improvements permit by_
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*Contact a representative of the Davie County Health Department for final inspection of this aynhom between 8:30-
9:30 A.M.
:3O'8:3OA.M. or 1:00'1:30 P.M. On day Of completion. Telephone Number: 704'834'5085.
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6'Fina| Installation Diagram: System Installed by
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Certificate ofCompletion Dote
'The signing of this certificate shall indicate that the oyuh»m 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.
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INFORMATION FOR SEPTIC SYSTEM REPAIR PERMIT
NAME e.� h e <- C PHONE NUMBER Q
lames ri �e
ADDRESS R 3. o SUBDIVISION NAMEUi4d
ie r
Ad U SUBDIVISION LOT #
DIRECTIONS TO SITE 1�� - ��� LK D / l
2
p t"'1 er
DATE SEPTIC SYSTEM INSTALLED
NAME SEPTIC SYSTEM ORIGINALLY INSTALLED UNDER
SPECIFY PROBLEMS THAT ARE OCCURRING
DATE REQUESTED INFORMATION TAKEN BY