1847 Hwy 801N DAVIE COUNTY HEALTH DEPARTMENT
(Septic Tank) Improvements Permit and Certificate of Completion
(Ground Absorption Sewage Disposal System - G.S. Chapter 130-Article 13C)
OWNER OR CONTRACTOR = ^' !` DATE - - f S " PERMIT
LOCATION ^+} �^ ' N� 51
.f Vol+`'.1^.ti l�.. t PKw.
S.R. NO.
SUBDIVISION NAME LOT NO. SECTION OR BLOCK NO.
HOUSE ) MOBILE HOME BUSINESS ❑
N0. BEDROOMS ,;; House Trailer 800 Gal. 400 Sq. Ft.
NO. BATHROOMS Two Bedroom House 800 Gal. 600 5 F.t.
GARBAGE DISPOSAL UNIT YES ❑ NO ❑ Three Bedroom House ,;'"9004Ga1:s r'"-900 Sq.,,..,Et�
AUTO. DISHWASHER YES ❑ NO ❑ Four Bedroom House 1000 Gal. 12016--Sq. Ft.
AUTO. WASH. MACHINE YES ❑ NO ❑
SITE SUITABLE _ YES ❑ NO ❑
SIZE OF TANK gal.
NITRIFICATION FIELD Al�'(7 sq. ft.
DEPTH OF STONE IN LINES:
WATER SUPPLY: Individual < Public ❑
IMPROVEMENTS PERMIT BY `��:f �', . :,.,._.1 F t INSTALLED BY
CERTIFICATE OF COMPLETION By_ A`LC o Date '7•�
(8/16/73) *Construction must c mply with all other applicable State and local regulations
LOT AREA
r:
Form Approved.
Budget Bureau No.76-R376.2.
VETERANS ADMINISTRATION
REPORT OF INSPECTION, INDIVIDUAL WATER SUPPLY AND SEWAGE-DISPOSAL SYSTEM
(TOP SECTION TO BE FILLED IN BY VA.)
REGIONAL O►FKE PROPERTY ADDRESS /l SUBDIVISION NAME
/
(Y [e!YL/A4C f d r� a�) BLOCK NO. LOT NO.
NAME Of BUILDER NAME OF LENDER CASE NO.
4!�,, ea'Ld tlr~ a•3 739S
D/r 4 55,y
5, gU �/j0e`6 U`, /�
TYPE OF INSTALLATION
/1T / CJ !/ w( !C ( ff
❑ NEW ❑ EXISTING
TOTAL NUM EER BASEMENT CAN ATTIC OR OTHER AREA BE MADE INTO IF YES,HOW WATER SUPPLY AND SEWAGE DISPOSAL(Check)
ADDITIONAL BEDROOMS? MANY?
LIVING UNITS BEDROOMS OATHS N YES PUBLIC COMMUNITY INDIVIDUAL
WATE
SUPPLY BY
( f❑ NO E] YES NO
SEWAGE DISPOSAL BY
PAST I—FOR USE OF INSPECT111 OFFICIAL (Fill in below information opplicablo to subject installation)
INSTRUCTIONS: If now installation, inspect,for tomplionco with approved exhibits and record any observed information not shown on,or which varies from,
tho approved exhibits. If existing installation, furnish as much of the information as may be available. As applicable u:a inspector's stetch on reverse.
INDIVIDUAL WATER SUPPLY SYSTEM
Distance to nearestp blie water main, :IeS feet. Size of main, inches.
Individual walls are 0 are not customary in neighborhood.
Give mast recent record of failure of wells in immedioto vicinity to furnish adequate supply of water Ypd9 W V'-
Properties in noighb*o�ihood ffooro 0 are not being developed with both individual water-supply and sewage-disposal systems.
Lot size: SGO'f feet wide, feet deep. Dwelling sal back from front property line, 7s feet.
Individual water supply from: Drilled well. 0 Driven well. ❑Dug well. ❑Bored well.
Distonce of well from
Cuilding foundation, ' ' feet;nearest lot lino of 0 front,�'side,0 rear, feet;
cost iron sewer, �oAl E! feat;file sewer, zYe feet;septic tonX feet;disposal field, 1'4510't feet;
seepage pit, feet;Acesapool, _foot;other sources of possible pollution, feet.
Well construction:
Diamotar, inches. Total feet. Typo of casing, ��l U t'ze� _Depth of casing, 3J foal.
'
Anproximato daplh of pumping level of water in wall, feet. Approximata yield, + gallons per minute.
Saand watertight to depth of 3S feet.
Exteriol space around casing sealed with: &I Cement grout. []Puddled cloy. 0 Ordinary backfill.
Wolf cover:" 0 Concrete. 0 Wood. Metal. Openings in well cover watertight: ffYos. ❑No.
Pump: [❑Shallow we11. D:,ep woll.'`Length of drop pipo, 2foot. Pump capacity,�gallons per minute. / T'..
Laceted in: [�Cas mer,. ❑Pump room off basement. Pump house above ground. ❑Pump pit. S[(b�LeYS Sc
Pump room properly drained:' .Yes. 0 No.''Pump mounting watartight; C]Yes. 0 No. ,
Type of mraga Pressure. []Gravity. Capacity,_�/_D gallons. f7 L's
Pas ba zrwl:,Uicel Qex ...L-11i0�of wclo been mudei Yes. 0 No'. If answer Is"yes,"give date ,.191__....
Quality of water�Is[]is not sotisfattary for human consumption. �•
in:tallatiln does[]does not comply with approved exhibits, if any: -
INDIVIDUAL SEWAGE-DISPOSAL SYSTEM
PRIMARY TREATMENT consists of 0 Septic tank. []Cesspool.
Septic tank:
r
Distance from well, DQ'rt feet. Material, eerly4y-ee E 6)n e re` �= Number of comportments
Total liquid capacity, JDoD gallons. Capacity inlet compartment, agallons.
Imide length, feet. Inside width, feet. Liquid depth, fact.
Cesspool.•
Distance from: Y/ol �faot;foundation, feet;nearest lot line at 0 front,Q side,Q rear, feet. "
Inside diameter, Depth, as liquid capacity, gallons. lining motorial
i
SECONnARY TREATMENT consists of Distribution box cndATile disposal Bald. ❑Scopage pits. Other
Tile disposal Aold:e''
Distance from. Well, fret;foundation, :Y-D feel;nearest lot line at❑front, side,El rear'. feet.
r?S Distance between linesfeet.
Total length of file lines,_feet. Numbmr of lines,. •
Toil effective absorption area in bottom of tronChas, square feat. .Trench widen, inches.
L:ngth of each Lina, S Rt feat. Depth,top of filo to finish Credal inches.
Typo of fsltar motorial: 0 Gravel.�Qpakan stone. 0 Cinders. Other
Dep$of filter malarial beneath tile, inches. Depth of filtor material over tile, 9Z inches, ,
Seepage pits:
Number of pits, Outside diomotor, feat, Depth, fact. Lining material
Dittonco from Via fact;found, on, feet;nearest lot lina at front,0 side,0 rear, feet.'
If existing installation,give oil t%z following c 'ional information available:
Didanca to merest: Public saver; /e5 foot," Com`m`u''nity syttsto``m, feet.
Appreximata direction of surface drainage-of lot, VO Y`!� ' Approximate slope, fact per 100 fact.
Soil is: 0 Loam., 0 Sandy I rm. Clay. 0 Sandy clay. ❑Coarse sand or gravel.�tlerdpnn. 0 Rcck. Other 814 kT�or�n SQwdsa
^ms, tharo a basement? ' Yes. '0 No, Casement dreia to SLl T`�Q CE'
tieures n bas-rat: ❑Lcut:-ry1 y, .,E]Tcilat. 0 MWub,:0 Showor. 0 None. M Floor drain. ❑Sump pump. r
Laundry wcta di o�W 'lj Direct b See a paa pit. °Oto• Z +<<C �!rt�s r� = Through sump pit to: 0 ScptK tank. 0 Seepogs pits.
• hf O e
Is fzting drain pror'xlsd? r Yes. 0 No.,,Drains to: Surface. 0 Dry wall. 0 Sump in basement Other
Down:Prts or crca=y dram to: Surface dfscharCa. Dry;wall. O:hor
Dap')of house sever b*law Rni:h Croda at foundaticn, '-s foot.
PART
((Continv3d.on favors,)
VA FOrstt 5 CXIDTING 0TOCK0 OF VA FOnIJ 20-0900
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