176 Latham Farm Rd DAVIE COUNTY HEALTH DEPARTMENT
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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 /!.tip /� Date. r d t.214 j
-�-
Location ,O — ? , /460 ' /�,4'„P..�/ ✓�' � ,� .�s'
Subdivision Naam��,, --eLot No. Sec. or Block No. a i
Lot Size C;GS� Housey Mobile Home _ Business Speculation
No. Bedrooms — No. Baths No. in Family _
Garbage Disposal YES ❑ NO p---" Specifications for.System:
Auto Dish Washer YES NO ❑ �, �� ..
Auto Wash Machine YES T NO ❑ `
Type Water Supply --- `_ Cai , .3ri� '`�'
`This permit Void if sewage system described below is not installed within 36 months from date of issue.
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Improvements per 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� t
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.
,
" DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
R O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name Max and Sherry Angell Datej X
Address Lot Size
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position S S
PS PS
U U
2) Soil Texture (12-36 in.) Sandy, S S
Loamy, Clayey, (note 2:1 Clay) PS PS
U U
3) Soil Structure (12-36 in.) S S
Clayey Soils PS PS PS PS
U U U
4) Soil Depth (inches) S S
4 A) PS PS
U U U U
5) Soil Drainage: Internal S S
(b (;v PS PS
U U U U
External � LS S
PS PS
U U U U
6) Restrictive Horizons
7) Available Space S S. S S
PS PS PS PS
U U U U
8) Other (Specify) S S S S
PS PS PS PS
U U U
9) Site Classification
U—UNSUITABLE S—SUITABLE PS—Provisional{y Suitable
Recommendations/Comments:
r
Described by Title �� Dat
SITE DIAGRAM
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APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT '011/k . ,
Davie County Health Department
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone (�qg_3104T
1. Permit Reau sted B AnCAQ Business Phone May 7a3'C11n57o
2. Address "R4 I C &'700,2
3. Property Owner if Different than Above " �-
Address
4. Permit To: a) Install--L Alter Repair
b) Privy Conventional Other Type
Ground Absorption
c) Sub-Division Sec. Lot No.
5. System used to serve what type facility: Housed 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 10X 3F3
Bed Rooms_ Bath Rooms_Den w/Closet
b) If Business, Industry or Other, State: Number of persons served �I
What type business, etc. NO
Estimate amount of waste daily (24 hours) NA
7. Number and type of water-using fixtures:
commodes a urinals garbage disposal
lavatory a showers washing machine 1
dishwasher sinks 3
8. a) Type water supply: Public Private V*" Community
b) Has the water supply system been approved? Yes No
9. a) Property Dimensions ion X a�2
b) Land area designated to building site cq a6 aj LaA�1}
c) Sewage Disposal Contractor
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.
Date ne ignature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
{ / Allow 5 days for processing
Directions to property:
(00 N hmm /z, �l
AA,d .
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