322 Cleary Rd (2) h r
DAVIE COUNTY HEALTH DEPARTMENT
,. IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
-41
*NOTE: Issued in Compliance with G.S. of North Carolina Chapter 130 Article 13c
Se age Treatment and Disposal Rules (10 NCAC 10A .1934-.1968) Permit Number
Name Date 11
1 6
Location - ; �, .� � ',�' ��; ��� .i �� /�/ {✓'/ ,%���' —
Subdivision Name Lot No. Sec. or Block No.
Lot Size !i' House Mobile Home l/ Business Speculation
No. Bedrooms 'J No. Baths No. in Family —
Garbage Disposal YES ❑ NO ❑- Specifications for System:
Auto Dish Washer YES NO
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.
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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 1:00-1:30 P.M. on day of completion. Telephone Number: 704-634-5985.
Final Installation Diagram: System Installed byC �� t t�
G c c_� ,
Y
I �
Certificate of Completion /0-�; �� -(r-Dat Z-2-2 "
*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.
RECEIVES
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section
R O. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone q I g - .5
1. Permit Requested By r 3 Lj 1,5 h e r Business Phone 1P34 — .590 1
2. Address '}' o cKS u ` N 7 0 2
3. Property Owner if Different than Above �yO h Y\n y YY-\ , -S r J h e r-
Address R-- (p C3h)( 1:56 -. 14 rnOC,k-SU 11e. MC, a176ZI
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 Homed Business
IndustryOther
b) Number of people
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions I b y 0
Bed Rooms Bath Rooms ')N Den w/Closet a
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 r
dishwasher sinks
8. a) Type water supply: Public PrivateJV00' Community
b) Has the water supply system been approved? Yes NoV.,
9. a) Property Dimensions 9- QC )reS
b) Land area designated to building site
c) Sewage Disposal Contractor nn
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.
' kZ0
T—teaOwner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
6 4 u)-es--Y A--`�j -� ��e-
30
Yk
DCHD(6-82)
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
AD PS PS
U U U U
2) Soil Texture (12-36 in.) Sandy, _ S S
Loamy, Clayey, (note 2:1 Clay) PS PS
U U U U
3) Soil Structure (12-36 in.) S S
Clayey Soils (/ P PS PS
U U U U
4) Soil Depth (inches) � S S
P PS PS
U U U
5) Soil Drainage: Internal S S
PS PS PS PS
U U
External S S
p PS PS
U U U
6) Restrictive Horizons
7) Available Space (`S� S S
Is PS PS
U U U U
8) Other (Specify) S S S S
PS PS PS PS
U U U U
9) Site Classification
U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable
Recommendations/Comments:
Described by Title Date
SITE DIAGRAM
DCHD(8-82)
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DEED MAGNETIC -
DENNY B. ROLLINS
D.B.63 PG.327
RB.66 PG.281 60
.' NIP
59.6 S 87° 51' 52" E
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327 3 NIP ,
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DENNY B. ROLLINS
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AREA = 0.674 ACRE
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eIP, S 87 51 52 260.00
443.13
NIP N 87°51' S2"W
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98.3 _
. STACY A. BECK
D.B.113 PG.687
., LEGEND .
EIP=EXISTING IRON PIN
NIP= NEW IRON PIN
NOTE : ASSUMED `ELEVATIONS
TOLERANCES SURVEY FOR:�1 o�ro� • REVISIONS
.. IEXCIF"AS NOTED) - -
�e••Gss�;°�.��� 3, �JI�ADY TUTTEOV1. CcT'•FY THAT UNDERND. DATE BY OY D ROL LI N
.. �. ••�� _ o. + DECIMAL
��..//�t t Y�iF.cL '+:��t AND1,N,T4 MAP + BEING 0.674 ACRE. TAKEN FROM THE DENNY B.
rJ E A! WAS bt AWN I RaM A�+.ACTU 4.:Fic(D 2URVEY ± ROLLINS PROPERTY(D B.63 PG.327,QB..66 PG.281).
1. 2527 ., r- R z LYING IN THE-CLARKSVILLE 'TWSP,DAVIE CO. N.C.
;iADE BY TU kERC'jY SURVEYIING CO.
FRAC TIONAL
DRAWN BY KALE p 1 MATERIAL ..
'• G �'�rr.`isy :l�`� TUTTEROW SURVEYING CO. +_ a SPH: 1=30
r ��••<.• ` • ,,pp T�--}}}}--_� - CHK'O .. DATE DRAWING NO.-
•...•• ROUTE 6 BOX 129 F ANGULAR 4
r GLT 3-31-82
REGi�
RED � L 2527 I�O..KSVILIE� N. G 4PZ-5bib TRACED APnD 50822