143 Lat Whitaker Rd y= DAVIE COUNTY HEALTH DEPARTMENT LAr
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
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 S/1�/ /� NO— iJ7
Location D�' .��I��. �� S4,k
Subdivision Name _ Lot No.
Sec. or Block No.
Lot Size / i House Mobile Home Business Speculation
J j
No. Bedrooms No. Baths No. in Family _
Garbage Disposal YES p NO p' Specifications for System:
Auto Dish Washer YESNO
Auto Wash Machine YES �j NO p
Type Water Supply lit/�r/ G�i��•�/c�
"This permit Void if sewage system described below is not installed within 36 months from date of issue.
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
1
Alal:t4-
Certificate of Completion Z Z Date 641
*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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APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department
B� Environmental Health Section
R O. Box 665 RECEIVED APR 2 1X989
-( v Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone
1. Permit Requested By Business Phone f
2. Address e— n'
3. Property Owner if Different than Above
Address
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
Industry Other
b) Number of people --
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions / y x7d
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 washing machine. �—
dishwasher sinks
8. a) Type water supply: Public Private Comm unity
b) Has the water supply system been approved? Yes 4," No
9. a) Property Dimensions
b) Land area designated to building site ,�'� 7-
c) Sewage Disposal Contractor
10. Do you anticipate any additions or expahsions of the facility this sewage system is intended to serve?
What type?
This is to certify
Qthat the information is c t to the best of my knowledge.
Z_//!9/ U
Date Owner Signature
'\ OWNER IS SOLELY RESPONSIBLE FOR COMPLI NCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
_; y
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section.
P. 0. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name 6 AL Date
Address Lot Size
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position . SS S S
2) Soil Texture (12-36 in.) Sandy, S
Loamy, Clayey, (note 2:1 Clay) S Is
TS
3) Soil Structure (12-36 in:)
Clayey Soils S S
U
4) Soil Depth (inches)
PS F S DS
U
5) Soil Drainage: Internal
PS• S S
External
F S F S
lam/
6) Restrictive Horizons
7) Available Space S
S PS S S
U U
8) Other (Specify) S S
PS PS S S
U :A U // I
9) Site Classification P
V I4 S
U—UNSUITABLE S—SUITABLE Ps—Provisionally Suitable
Recommendations/Comments: �;9n
Described by � �� Title � ' Date
SITE DIAGRAM
X
z2 '
�3
UCHO(6-82)
Davie County Nealtfi De aitnent
and .dome Nealtfi Ayency
210 HOSPITAL STREET/P.O.BOX 668 -
MOCKSVILLE.N.C. 27028
PHONE:(704)634-5985
May 2, .1989
ti
Potts Realty
P. 0. Box 11
Advance, NC 27006
Re: Site Evaluation
State Road 1432
Harry Moore
Dear Realtor:
On May 2, 1989, as you requested a representative from this office
visited the above mentioned site. The soil was found provisionally suitable
for the installation of a ground absorption sewage system.
If you have any questions, please feel free to contact this office.
Sincerely,
Robert B. Hall, Jr., R.S.
Environmental Health Section
RH/wd
Enclosure