P5575 Gladstone Rd DAVIE COUNTY HEALTH DEPARTMENT so. 00
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION b D 3U.
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 Date �: - L 7 N0 17
Locations
:•�� , �. '�. - :.i �, ;tom.. .�).iiJ-a...\.z.... '-�.�=2. ,:':j.l),a..�':> , `�
Subdivision Name Lot No. Sec. or Block No.
Lot Size 1 yy House ' Mobile Home _ Business Speculation
No. Bedrooms '� No. Baths _ No. in Family
Garbage Disposal YES ❑ NO Q Specifications for System:
Auto Dish Washer YES [ NO ❑ �, Z" - ,
Auto Wash Machine YES E2 ' NO -❑
Type Water Supply
'This permit Void if sewage system described below is not installed within 36 months from date of issue.
I
1
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
j
r
Certificate of Completion \C \ �� . ' 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.
• �, APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section RECEIVED MAY 1 0 1
P. O. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
f T Home Phone
1. Permit Requested By Business Phone -3 "_.��9-
2. Address �WjkFE
C,
3. Property Owner if Different than Above
Address
4. Permit To: a) Install Alter Repair
b) Privy Conventional L Other Type
Ground Absorption
c) Sub-Division Sec. Lot No.
5. System used to serve what type facility: House Mobile Home.�Business
Industry Other
b) Number of people
6. a1 If house or mobile home, state size of home and number 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 ?, urinals garbage disposal
lavatory showers 7�m L", washing machine
ej
dishwasher sinks r
8. a) Type water supply: Public PrivateCo munity
b) Has the water supply system been approved? Yes No
9. a) Property Dimensions
b) Land area designated to building site
c) Sewage Disposal Contractor
10. Do you anticipate any additions or expansions of the facilit this se age system is intended to serve?
What type? l� 1� f3 1 ccs ry . ct a ✓ �3 �5'l1�U lam( nxsf'
0.i�1u my-le- PT� hAj
This is to certify that the information is corr/ectt to the best of my^knowledge.
Date Qwne S(r gnature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
=ut'-wtj Dom- Gls � a
4—k-e rl hTi I %` r 15/V Q-{— Eicso{ d dr jj ecva' ;e �
f iDe,
DCHD(6-82)
Excise Tax Recording Time,Book and Page
TaxLot No. ..... .. ......... .......I.... .................... ..................... Pgrejel Identifier No. ..........................................................................
Verifiedby ......................................................................... County on the .......... day of .......................................................It 19.... ....
by ................. ......................................................................................................... . .... ........... ........................................................I..................
. ..
Mailafter recording to ........................................................................................ .. ........................................................................................
..........I....................I..............I.......................I............I........................ .......... .......................................................................
This instrument was prepared by ... .............William E............................Hall, Attorney........ ................ .. .....at.......Law......................................................................... .....
Brief description for the Index I
N01&?%TH CARDLINA GENERAL WARRANTY DEED
THIS DEED made this 17.0.......... day of .................APPU........... .......... .... ild by and between
GRANTOR GRANTEE
THOMAS JACKSON LAGLE, SR. and THOMAS JACKSON LAGLEj JR.
wife# &4LLA NICHOLS LAg"
Enter In appropriate block for each party: name, address, and, U appropriate, character of entity, e.q. corporation or partnership.
The designation Grantor and Grantee an -used herein shall include said parties, their heirs, successors, and 4asigna, and
shall include singular, plural, masculine, feminine or neuter as required by context.
WITNESSETH, that the Grantor, for a valuable considerutiun paid by the Grantee, the receipt of which is hereby
acknowledged, has and by these presents does grant, bargain, sell and cunvey unto the Grantee in fee simple, all that
certain lot or parcel of land situated in the City of ........................................ ................... ............4.0.0.41091............. Township,
Davie
................... County, North Carolina and more particularly described as follows:
..................................
BEGINNING at a Led Oak, a corner for Paul Wagner and Jack Lagle lines, runs thence
with Jack Lagle lima North 03 dog. 10 min. East 267 feet to an iron stake; thence
a now line South 87 deg. 35 min. East 175 feet to an iron stake in the T. J. Lagle
line; thence with the T. J. Lagle lige South 09 deg. 30 min. West 269 feet to an
iron stake in the Paul Wagner line; thence with the Wagner line Westwardly 150
feet to the Beginning, coutataiqg One (1) Arco, more or leap.
N.C.Bar Au".Form No.3 Q)1976,Reviwd 0 1977-jwm wwwm a ca..inL.so4 in.ywka-4110.N.C.37064
P99444 by Ar"RWAIMAWIX Q&V Alaw-I Y61
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section.
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name Date
Address S A '� Lot Size n�-
FACTORS A ARZ;� AREA'S—S ARE 4
1) Topography/Landscape Position PS SS
U U
2) Soil Texture (12-36 in.) Sandy, S
Loamy, Clayey, (note 2:1 Clay) ( S
`-t7� U
3) Soil Structure (12-36 in.) S
Clayey Soils
4) Soil Depth (inches) S
P PS
U U
5) Soil Drainage: Internal
U
External
P P ZU
6) Restrictive Horizons
7) Available Space
PS
U C P PS
8) Other (Specify) S S S S
PS PS PS PS
U
9) Site Classification
U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable
Recommendations/Comments: T -
Described by , Title Date
SITE DIAGRAM
DCHD(6-82)