192 Bear Creek Church Rd (2) l4 '1 .—. _•..y„ ...a-.•w•'++•- -.wi1T'14+��I8'IIG'?��WiQir.sN"V€"LY. "wCxslili"'7�9Hri`F$'8 ni"rowrWNQiiiW'�7+ OY14W4b+n.....am�a.vrpww r.e -_ ..____ - - - ..
DAVIE COUN :II HEALTH DEPARTMENT
IMPROVEMENTS-PERMIT AND CERTIFICATE OF COMPLETION
'NUT E:. Issued in Compliance with'G.S of North 'C `II lina Chapter 130 Article 13c
Sewage. Treatment and. Disposal Rules (10, C�O�.1934-.1968) Permit Number
Nam s}. �,.c� t,mac•�._ �*. ' I' Date }
e _ u� v
Location C) 1 _ �r� •'c�c , �t' ' c Sy. s r,'y�s7C` \�`r ''��� " x •.5.9•..
Q,�-divi;ion-Name I Lot No. Sec. or Block No.
Lot Size House- Mobile Home_ ;Business Speculation �.
No. Bedrooms No: Baths it
No..in Family._, .
Garbage Disposal .,:YES' ❑.. NO
Specifications for System:
Auto Dish Washer YES 0 NO, !
►� , '/ c�,c,� <. ;g,;—� .�_ • `� _ Jam,
Auto Wash Machine YES NO ❑ oU <
X moi,
C0� v .
• Type Water Supply •
*This permit Void if sewage'system rdescribed`below II not installed within 36 months from date of issue.
i Improvements permit by._ �A
•`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: T dI ephone Number: 704-634-5985.
Final Installation Diagram: 1 ' System,Installed bye - -
-� has.
;fie
Certificate of Completion G� Date A0 1191
* "The'signing oflthis.certificate.shall indicate that the syster' described above has been installed in compliance with
the stand`ards'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 Q
of*
Davie County Health Department F�
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone y7t5* 7
1. Permit Requested By Business Phone
2. Address
3. Property Owner if Different than Above
Address
4. Permit To: a) Install-jeff-Alter Repair
b) Privy Conventional-A/—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 3
6.. a) If house or mobile home, state size of home and number of rooms.
House Dimensions 7
Bed Rooms,3 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—k—'_ Private Community
b) Has the water supply system been approved? Yes_ZNo
9. a) Property Dimensions 61 7# & .f Jtg�/
b) Land area designated to building site IZ44xd�
c) Sewage Disposal Contractor
10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve? ,MAI—,
What type?
This is to certify that the information is correct to the best of my knowledge.
4-1_1_11,2LLQAA4 14 10Z r1 azC4 C-.1 41��c�litill
to Q Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
411
W--L` - /YJ . � 7 M 3
7 77 6 7 63
-DCHD(6-82)
_ a-
w' 69. F 64DEN i
920.9 E i
9 ' E. R MELTON
A/ 1696,69 TOTAL 11 B. 78 PG.623
O1 C/ 460.65 I i
1100 A RFS ��-- I
925.93
10.0
00
1p �0 AC pew - -
MARTIN A WALKER o m$ r 11.�4_ O E. R. MELTON
D. R. 75 PG. 342 Y9 L^p w C D 8.128 PG.691
Z 0 p
W ry� p
t N • P
ry N
ALBERT SNOW
D.B.84 PG.338\ 'BED' I
� E.R. MELTON
oA ,0 �D.8, 102 PG.739
Gam.
'•�r I - °� l y� I I DOUGLAS R JONES
D.B.104 PG. 427
-. E S. T6°26•x.. E ag00``'l I �/ 1
ROAD— , T TOTAL
510.142 w,,, \ r �5
.�qE! r• __�___ 164.79 266.66 169.62 TT.O 246.66 266.67 _ __ ALONZO MAGE
D.B.62 PG. 483
416.29 I.I.LW �—•570.37 TOTAL Eau al ft rE
O N N
W b y
I0.I55 ACRES ^r°
VERNON E DAETWYLER
•� �O ��/
0.B. 86 PG- 171
LEGEND
b •;J
,t •r J
r
44 ON
A
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name R Date
Address Lot Size •� ��'�'
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position S S
PS S PS PS
U U U
2) Soil Texture (12-36 in.) Sandy, S S S S
Loamy, Clayey, (note 2:1 Clay) (IR5 PS PS
U U U U
3) Soil Structure (12-36 in.) S S_ S S
Clayey Soils PS-) OPS PS PS
-u— U U U
4) Soil Depth (inches) S S S
PS PS PS
U U U
5) Soil Drainage: Internal S S
PS PS PS
U U U
External A,
PS PS
U U U U
6) Restrictive Horizons
7) Available Space S S
PS PS PS
U U U
8) Other (Specify) S S S S
PS PS PS PS
U U cc U U
9) Site Classification
U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable
Recommendations/Comments:
Described by
� � �–� Title �`� Date
SITE DIAGRAM
F
H
Ja
DCHD(6-82)