380 Stroud Mill Rd (2) .y .'i M- a •'i
DAVIE COUNTY HEALTH DEPARTMENT � 3S
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 V--,) S1� S'-_ N2 Date E'`� r N2 5556
Location �TA ya N ,,J � =� � •
Sub id vision NameV� ` Lot Nd. Sec. o� No
Lot Size J rsa House Mobile Home _ Business Speculation
No. Bedrooms No. Baths 3 �- No. in Family 3
Garbage Disposal YES p NO
F.; Specifications 'for System:
Auto Dish Washer. YES [D! NO p
Auto Wash Machine YES NO / o- s) off` z) I � '
,�
Type Water Supply �� -� _ ✓
4_
*This permit Void if sewage system described below is not installed within 36 months from date of issue.
LL T
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�T c�
?s f
r
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 �'�' 3 0
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
NTe - N 5556
Date � �� �� �
Location >
Subdivision Name Lot No. Sec. or B16)ek No.
Lot Size J tIN\ House Mobile Home _ Business Speculation
No. Bedrooms H No. Baths No. in Family _
Garbage Disposal YES .❑ NO Q/ Specifications for System:
Auto Dish Washer YES NO p
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.
4-)
1
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 -.-,
v ZIP
- 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 functiott
satisfactorily for any given period of time.
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
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 704-492-5933
1. Permit Requested By Lynn Pt. B e u t e r Business Phone
2. Address Rt . 1 . Box 330AA, Harmony , NC 28634
3. Property Owner if Different than Above A q u a j e t East , Inc .
Address Same
4. Permit To: a) Install X Alter Repair This will be for an addition on existing house .
b) Privy Conventional Other Type x septic tank
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 1800 s f 2 story
Existing : Bed Rooms 3 Bath Rooms 2 1/2Den w/Closet 1 addition to include 2 bathrooms
b) If Business, Industry or Other, State: Number of persons served and 1 bedroom
What type business, etc.
Estimate amount of waste daily (24 hours)
7. Number and type of water-using fixtures: on addition
commodes 2 urinals garbage disposal
lavatory 2 showers 2 washing machine
dishwasher sinks
8. a) Type water supply: Public Private x Community
b) Has the water supply system been approved? Yes No
9. a) Property Dimensions 24 . 75 acre s
b) Land area designated to building site 28 ' X 48 '
c) Sewage Disposal Contractor Tn m fl i x on R a r k h n p S p r v i r p
10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve? no
What type?
This is to certify that the information is correct to the best of my knowledge.
April 27 , 1989
Date Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
Highway 64 West from Mocksville to Highway 901 . Turn right at 901 .
Travel approx . 1/2 mile to first dirt road on left ( County Line Rd .
goes to the right) . Follow dirt road approx 1 mile to two story house
on right . Address on black mailbox "Rt . 1 , Box 330AA" . Columns with
pineapples at entry.
DCHD(6-62)