120 Starlight Ln t ;z DAVIE COUNTY_HEALTH DEPARTMENT
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 -OA .1 34-1968)"'." Permit Numb&
Il Name / X1 ' 5
i ;Date /`J i �.
a t� :
'� Ldbati"on L '�f I'1✓�4 G i' tr% ( cf J _ 4 'R �Y l �! � '
;r
Subdivision Name'_ Lot No. Sec. or Block No.
Lot'Size House, Mobile Home �/� Business Speculation
I! No. Bedrooms No. Baths _ No: in Family
li Garbage Disposal YES 0 NO Specifications for System:
Auto Dish Washer. YES
NO.
Auto Wash Machine a;.•YES. � NO•'�, '' - � � . '
Type Water SuPPIY /n.
*This permit Void if sewage system:described below is not installed within 36<months from 'date of issue. .
rajf
+r • ' '� Improvements permit by � -
��. *Contact a representative of the'bavie-County Health Department for final inspection of-this. systema between 8`30-
9:30 A.M. or.1:00-1:30 P.M.. oh�i day of completion. Telephone Number: 704-634-5985.
Final Installation Diagram: System Installed by `
�0
6.
G �
%
• F ti Certificate of Completion /y1 Date `�✓�� }{
The signing of thiscertificatelshall,'•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.
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department 0
(� Environmental Health Section p►Q�
P. 0. Box 665 CC� �
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
lHome Phone
1. Permit Red B ( 96Business Phone
equ
2. Address (609 Y '
3. Property Owner if Different than Above = T �•L
Address
4. Permit To: a) Install A tl er Repair Z 1_X
b) Privy Conventional tL-56ther Type—
Ground
ype Ground Absorption
c) Sub-Division Sec. Lot No.-
5.
o.5. System used to serve what type facility: House Mobile Home Business—
Industry—
usiness IndustryOther
b) Number of people
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions -�4 X 76
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 2 urinals garbage disposal
lavatory showers washing machine
dishwasher / sinks
8. a) Type water supply: Public Private Community
b) Has the water supply system been approved? Yes No
9. 'a) Property Dimensions P12 -
b) Land area designated to building site
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.
39-_1
Date Owner Sign re
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
13}a
o
DCHD(6-82)
` DA VIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
R O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name
/vo yDate A2
Address Lot Size 61
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position S S S S
PS PS PS PS
U U U
2) Soil Texture (12-36 in.) Sandy, S S S
Loamy, Clayey, (note 2:1 Clay) PS PS PS PS
U U U
3) Soil Structure (12-36 in.) S S S
Clayey Soils pS PS PS PS
U U U
4) Soil Depth (inches) S S S
PS PS PS
$U ) U U U
5) Soil Drainage: Internal S S S
d�) PS PS PS
U U U U
External S S S
PS PS PS PS
U U U
6) Restrictive Horizons ..—�
7) Available Space ;
S S S
S PS PS PS
U U U U
8) Other (Specify) S S S S
PS PS PS PS
U U U U
9) Site Classification rs I
U—UNSUITABLE S—SUITABLE PS—Provisionaliv Suitable
Recommendations/Comments:
Described by— Title yDate
SITE DIAGRAM
DCHD(6-82)
�tti�ie fl�vun#g �ettl#l� �elt�rr#men#
ttnb Mame Peal#h �genrg
P. O. BOX 665
�ucksbille, �arth ( arolina Z7a28
OFFICE OF THE DIRECTOR TELEPHONE
1704) 634.5985
May 5, 1987
Potts Realty
P. 0. Box 11
Advance, NC 27006
Mr. Potts:
On May 1, 1987, this office evaluated a 5 acre tract of land
owned by Rick Stanley on SR 1322 in Davie County.
The tract was classified provisionally suitable; however, no
home location was staked off. Please contact this office when the
proposed home is located.
Sincerely,
Robert B. Hall, Jr. , R.S.
Environmental Health
Enclosure
RH/wd