145 Iris Ln DAVIE COUNTY HEALTH DEPARTMENT
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X-A6 v°� IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
'4 NOTE'm Issued in Compliance with G.S. of North Carolina Chapter 130 Article 13c
Sew __ge Treatment and Disposal Rules (10 NCAC 10A .1934-.1968) Permit Number
Name ,,��frffr�/t/ �'i��r'' i �1r / .����U Date ✓ / N2 55
Location. `/-. �
Subdivision Name Lot No. Sec. or Block No.
Lot Size ? % 7;IZ4C` House — Mobile Home _ Business Speculation
No. Bedrooms No. Baths No. in Family _
Garbage Disposal YES 1XI NO p Specifications for System: /
Auto Dish Washer YES NO p
Auto Wash Machine YES NO C] 41 G
Type Water Supply
*This permit Void if sewage system describ below i of in i Iled within 36 months from date of issue.
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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 1:0011:30 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.
r' APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
r Davie County Health Department04 Ott
Environmental Health Section CCO S�Q 0
P. O. Box 665 CC��VG
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone��lq� S7�y-
1. Permit Requested By �u C- • Corl7a / Z e-1- Business Phone
2. Address / , 2 AV'X /73 kaw ae- . A G. ;Z�ao6
3. Property Owner if Different than Above ThdmoS In, Go✓.r►�zei
Address 4clyali ce_ k e, 2 006
4. Permit To: a) Install Alter Repair
b) Privy Conventional Other Type
Ground Absorption
c) Sub-Division Sec.—Lot No.
5. System used to serve what type facility: House Mobile Home Business
IndustryOther
b) Number of people
6. a�If house or mobile home, state size of home and number of rooms.
House Dimensions sclrc ns a Ndw.
Bed Rooms 3 Bath Rooms—2 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 3 showers washing machine
dishwasher f sinks
8. a) Type water supply: Public Private Community
b) Has the water supply system been approved? Yes �No
9. a) Property Dimensions Dprox, / acre- mvl e or less
b) Land area designated to building site /4s/if?G
c) Sewage Disposal Contractor s CAP e-
10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve?
What type?
This is to certify that the information is correct to the best of my knowledge.
Le2if:� -:
Date Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property: �rJo
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DCHD(8-82)
. DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section.
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name
Date
Address Lot Size
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position � S S S
P PS PS PS
U U U
2) Soil Texture (12-36 in.) Sandy, S S S S
Loamy, Clayey, (note 2:1 Clay) PS PS PS
U U U
3) Soil Structure (12-36 in.) S S S S
Clayey Soils ,per PS PS PS
0 U U U
4) Soil Depth (inches) S S S S
PS PS PS PS
U U U
5) Soil Drainage: Internal S S S S
PS PS PS PS
U U U
External �� S S S
(pSJ PS PS PS
`C�� U U U
6) Restrictive Horizons
7) Available Space S S S
PS PS PS PS
U U U U
8) Other (Specify) S S S S
PS PS PS
�J U U U
9) Site Classification
U—UNSUITABLE S—SUITABLE PS Provisionally Suitable
Recommendations/Comments:
Described by .�, , Title Date
SITE DIAGRAM
DCHD(6.62)
Davie County Nealtli De artment
a
and .dome NealtFr yi cy
210 HOSPITAL.STREET/P.O. BOX 665
MOCKSVIL.LE.N.C. 27028
PHONE:(704)634-5985
October 2, 1989
Lynn Hicks
124 Depot St.
Mocksville, NC 27028
Re: Sewage System Installation
Eddie Cornatzer
Fork Church Road
Dear Attorney:
The septic tank system that serves this residence was designed, .•
inspected and approved by this office on August 4, 1989.
With proper maintenance and use it should function properly.
Sincerely,
WL
Robert B. Hall, Jr. , R.S.
Environmental Health Section
RH/wd