137 Lakeside Drive Lot 134e_5/& b�2- "/ / z, / / ('-'
DAVIE COUNTY HEALTH DEPARTMEW ANK PERMIT Date
Owmer/Occupant To: L 10� d ,,<
Address 4O Address L,ej
Building Contractor f 2 Address
Cal. De Manufacturer's Name Address J&4
No. of lines �_ Width J �4.inn.. Total length ft. No. -sq. ft. j4zo .-3 tz;:�_
Type of filter material Total tons used
Minimum REquirements: House Trailer Tank cap. 800 Sq. ft. line 400
Two-bedroom house 800 600
Three-bedroom house 900 900
No one shall install a septic tank in Davie County without a permit from the Health Offi(
or his agent.
Date of Final Approval Signed:
Sanitarian
I hereby certify that the above septic tank has been instIle d accordi/ng� to specification
Signed:
Se is Tank Contractor
Note: Make sketch of disposal system on back of sheet and mail to Davie County Health
Center, Box 57, Mocksville, North Carolina 27028.
Davie County Health Department
Environmental Health Section
P.O. Box 848 )� �
210 Hospital Strect y
Courier # : 09-40-06
Mocksville, NC 27028 311
Phone: (336) - 753 - 6780 Fax: (336) - 753-1680
ON-SITE WASTEWATER CERTIFICATION
(Check One) Replacement Remodeling Reconnection
Name: _1� IT t� �� _ _ Phone Number -336-691-360 (Home)
Mailing Address:- LA" [ 88. A7(- (work)
Email Address: R,1 del �c7 Ce Q Ma ,r 6_1A
Detailed Directions To Site:
3
Property Address:.
n S� cr
Please Fill In The Following Information About The EXISTING Facility: L, 13 k
Name System Installed Under: & At.4 5Q t al d k ( e_ Type Of Facility:_
Date System Installed (Month/Date/Year): ! L Number Of Bedrooms:__�_Number Of People:
Is The Facility Currently' Vacant? Yes (30 If Yes, For How Long?
Any I{nown Problems? Yes No If Yes, Explain:_
Please Fill In The Following Information About The 1VEWFacility:
Type Of Facility: &416 Ja _aej Number Of Bedrooms: Number of People — -
Pool Size: — Garage Size: Other:
Requested Byjy 'CDate Requested: -5 – )
1 For Environmental Health Office Use Only
Approved Disapproved
Cnntrr�ents:
Environmental Health Specialist Date:. —57
*The signing of this form by the Environmental health Staff is in no way intended, nor should be taken as a guarantee
(extended or limited) that the on-site wastewater system will function properly for any given period of time.
Payment; Cash Check Money Order # Amount:$ 1te:
Paid By: Recelved By:
Account #:T�Invoice #:
Davie County Health Department
his ftp Environmental Health Section
P.O. Box 848
210 Hospital Street
Courier # : 09-40-06
Mocksville, NC 27028
Phone: (336) - 753 - 6780
ti
O
D
� m
y2
Far: (336) - 753-1680
ON-SITE WASTEWATER CERTIFICATION
(Check One) Replacement Remodeling Reconnection
Name: F I l 'F05l'e( Phone Number 336-697-3t'30 (Home)
Mailing Address: 137 LAk26 CIS„ Ari (Work)
Email Address:
Detailed Directions To Site:
6Teei'1 woo E L) r 13
Property Address:
Please Fill In The Following Information About The EXISTING Facility: (� 13 g k 3
Name System Installed Under: ..Q ` A K ( C— Type Of Facility: .5 -
Date
Date System Installed (Month/Date/Year): _Number Of Bedrooms:� _Number Of People:
r
Y Is The Facility Currently Vacant? Yes GL If Yes, For How Long?
Any Known Problems? Yes No If Yes, Explain:
Please Fill In The Following Information About The NEW Facility:
Type Of Facility: Number Of Bedrooms: Number of People
Pool Size: Garage Size: Other:
Requested By*�( YDate Requested:
(Signature)
For Environmental Health Office Use Only
Approved Disapproved
Comments:
Environmental Health Specialist Date:
*The signing of this form by the Environmental Health Staff is in no way intended, nor should be taken as a guarantee
(extended or limited) that the on-site wastewater system will function properly for any given period of time.
Payment: Cash Check Money Order # Amount:$ Date:
Paid By: �j Received By:
Account #: y�5 �'� Invoice #:
W.
•
/ 545
STATE OF NOE18 CAtOUNA-Dam Ceemtf.
/TffiS.DEED, NA& tab the 28th day „ r August lY 72 � by
Ralph Thomas White and his Wife Sara I. White
..r Davi• . ouoy. Stats d Nath CW*Ur^iP�rt-•° -Af the and pert. to
W),nired T ftdalde and wife Betty A. Sprinkle of Davie Comb
State of Nath Co ollsa, part-im.m d the aecoed part; Wltm mth That the rid partiS.A_ of the tint part In consideration of
($D.Q a.v.o Ten Dollars and other raluaj)jm Rpgeiderationa to
sham pow by the add parLL2A-Af the second part, the receipt of which is hereby aefmowleds4 ine(have barplow
sad sold, end by then premate da bwgabk nu and convey unto the saki p&bhLA.-of the second part and thoo r
heirs a ked or pared d Ismd In the Coanty of Davie and Sate of North Cavil—- M Shady Grove
Town,fA s4obkO4be400de-d
.asd• Mm sed bomdad a follows:
Lot -No. -Thirteen -(13), Block Three (3) Section One
(1) as shown on the revised plat of OhiWOOD LAOS
SUBISIVISION recorded in Map Book 3, ppaage 101, Davie
County.Regdatry, to which reference i, hereby made
for a more particular description.
The above land is sold subject to the Restrictive
Covenants recorded in Deed Book 57, page 453, Davie
Registry.
STAMPS PAID $4.00
9/6/72
. The above Lad were conve, to (Rentor by See Boob No- p :e
TO HAVE AND TO HOLD the efereseid trad a parcel of Lad and all pdvneges and appurgoanes thenmb bdamgleg to the
• rid psrt_llm d the es0tnd part nee 1 heir�n emd eedps foreem
And the ofd part."—of the Snt part that they /an edsed of nisi prm-� �-innh fee and
any 1� • iagi�e i %16"fm4at �fm� r 2972. I[tla.
wlB warrent and .viand of�b the rime aplaet the eiehn ON all person whatsoever /
IN TWMONY'" RZOT the oM pert� d the On, part --have �.....oto ntthei r "mod a 40d ..a a
RaInh Wh Th(Sul
) Sara I. White ()
oeu• a (Seed) Sara a (Sed)
(Seal) (Seal)
(Seal) (Seal)
STATE Or NORTH CAROLINA, Forsyth CaaW, Forsyth Co., North Carolina
I.Harold C. Weaver. Jr. a Notary Public, of saI&GAn nty, do, hereby certify
that Ralph Thomas White and his wife Sara I. White
granters, each persoodu eppeand before me this dq and wkoowledgd the a tion d the foresoloa deed of coevayanca
Wltoess my band emd mohmial nal this the 5th day of September , le 72
My commiryn e�(rea February 17 , 19Z Harold C. Weaver, Jr, seal) _ x, P.
STATE OF NORM CA1901AXA•--Davie Ce sty.
• The forpoIng certificate(z) of _Hare" a
in (aa) oertUM to be cornet. Thy Instrument was pseoented for reglskatlm thio 6 d„ of. September
19.7_, at , - P.M, and duly recorded In the office of the Register of Deeds of Davie County, Nath Carolina In
Book 86 , pap—l45— J. IL SM1TH, RZGIRM OT DEEDS
Thy ,, e 6 a•Y ttf 9aPtnmhsr , A.D., 19 72
By: Pauline Warner
DEPUTY REGISTER OF DEEDS.
This Instrument prepared -by: