446, 474 or 478 Jack Booe RdDAVIE-COUNTY HEALTH DEPARTMENT
'I:1
IMPROVEMENTS PERMIT AND CERTIFICATE .OF COMPLETION o�
*NOTE:.Issued in, Compliance with.G.S..of •NorthIParolina Chapter 130 Article 13c
Sewage Treatment and Disposal Rules;'(10 NCAC -10A .1934-.1968) - Permit Number
Name �/� i Date4.
4
-�
�. Locatio / !rs` iY'� �, y;• �'
Subdivision Name
Lot No. .Sec. or Block No
Lot Size 3`%rS. House Mobile Home* Business__ Speculation
No. Bedrooms�
. No.Baths q
_ No. in Family
Garbage Disposal YES [1 No Specifications for System:
Auto Dish Washer � , ;YES NG ����
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.
*Contact a representative of•the Davie County';: ealth 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 a
APPLICATION FOR SITE EVALUATION/ IMPROVEMENTS PERMIT
Davie County Health Department
1 I V Environmental Health Section
�f l P. 0. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
/ Home Phone % C� y8 70
1. Permit Requested By n!4 c cr G N Business Phone 2 9f' VE .2
2. Address n t A /.ecu �Q/L A /YJac vi/,F 702
3. Property Owner if Different than Above �✓� s r'1
Address W,5�01 - ile•c/,lz �✓-5.
4. Permit To: a) Install Alter Repair—
b)
epair b) Privy Conventional Other Type—
Ground
ype Ground Absorption
c) Sub -Division I Sec. Lot No.
5. System used to serve what type facility: House Mobile Home Business
IndustryOther
b) Number of people 12-
6.
2 -6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions / FO 5f fit,
Bed Rooms— Bath Rooms___ 2.__ Den w/Closet K
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 2 urinals garbage disposal
lavatory or- showers �- washing machine
dishwasher I sinks S
8. a) Type water supply: Public Private Community
b) Has the water supply system been approved? No i'
9. a) Property Dimensions
b) Land area designated to building site No.
c) Sewage Disposal Contractor
10. Do you anticipate any additions or expansions of the facility this sewage sysiem Is intended to serve?
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:
A/ r
DCHD (6-82)
Nb
Address
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section.
P. 0. Box 665
Mocksville, N.C. 27028
1 SOIL/SITE EVALUATION /
�✓ Date
Lot Size
GAr:Tr1RC AREA 1 AREA 9 ARFA 3 APPA A
6)
8)
I) 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) i(P PS PS PS
U U U
3) Soil Structure (12-36 in.) S S S
Clayey Soils PS PS PS
U U U
1) Soil Depth (inches) S S S
Qp� PS PS PS
U U U
i) Soil Drainage: Internal S S S S
PS PS PS PS
U U U
External S S S
PS PS PS
U U U
Restrictive Horizons
Available Space � S S S
S PS PS PS
U U U U
Other (Specify) S S S S
PS PS PS PS
U U U U
9) Site Classification
U—UNSUITABLE
Recommendations/ Comm
Described by
SITE DIAGRAM
�A I OW '�Prl
S—SUITABLE PS—Provisionally-Suitable
Title o✓ Date
DCHD (6-82)
."ice`
U—UNSUITABLE
Recommendations/ Comm
Described by
SITE DIAGRAM
�A I OW '�Prl
S—SUITABLE PS—Provisionally-Suitable
Title o✓ Date
DCHD (6-82)
."ice`
r 9a .� a 'E� a ` '�►
17
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gp
•Q wh ,t 40
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1 it L 642 q RoA.:I'. Pod'
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TAX LOT 4c
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Dam? County Nealin (Department
and .glome Ae-ala Ayency
21 O HOSPITAL STREET/ P.O. BOX 665
MOCKSVILLE, N.C. 27028
PHONE: (704) 634-5985
Tony Buchanan
Rt. 2, Box 216-A
Mocksville, NC 27028
November 12, 1987
Re: Site Evaluations (3)
Jack Booe Rd.
Mr. Buchanan:
On November 6, 1987, this office evaluated three acreage tracts at your
request on Jack Boos Road in Davie County.
All three tracts evaluated are classified provisionally suitable for
septic tank systems.
When your house is staked off, please contact this office, and we will
reevaluate the site and issue a septic tank permit.
Sincerely,
Robert B. Hall, Jr., R.S.
Environmental Health
RH/wd
Enclosure