2497 Cornatzer Road Lot 1T nV
DAVIE COUNTY HEALTH DEPARTMENT Gs%I/P
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_ ✓✓t�fr i l,ir - i.'
Date % %/ // J y;� 4143
Location r— r/977
I 1'6W_ ///Z' -
Subdivision Name 7 ` we'm
Lot No. Sec. or Block No..
Lot Size - House Mobile Home,
No. Bedrooms. No. Baths ='% No. in Familyf
Garbage Disposal YES ❑ NO -171
Auto Dish Washer YES ❑ NO ❑
Auto Wash Machine YES)❑ NO ❑
Type Water Supply /If�11
Business Speculations_
Specifications for System:
le^ovfZ.�
*This permit Void if sewage system described below is not installed within 36 months from date of issue.
Improvements permit by ;24 4 �
*Contact a representative of the Davie County Health Department for final inspection of this system between 8:30-
9:30 A.M. or 1 coo -1:30 P.M. on day of completion. Telephone Numb r: 704-634-5985.
Final Installation Diagram: Syste Installed by
Certificate of Completion / \ w" _ 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.
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.
1. Permit Requested By ;A
2. Address rte'/ yYloe
3. Property Owner if Different than Above
Address
4. Permit To: a) Install Alter— Repair—
Home Phone AN
Business Phone QpX' 09
b) Privy— Conventional— Other Type—
Ground Absorption
c) Sub- Division SEaEGfELO Sec. Lot No. -
5. System used to serve what type facility: Housed Mobile Home— Business
Industry— Other
b)Number of people
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions W IXZe"
Bed Rooms -3 Bath Rooms Z Den w/Closet
b) If Business, Industry or Other, State: Number of persons served
What type business, etc.
Estimate amount of waste daily (24 t
7. Number and type of water -using fixtures:
commodes 2 urinals
lavatory showers 2
dishwasher sinks
8. a) Type water supply: Public Private Community
b) Has the water supply system been approved? Yes,_ No -
9. a) Property Dimensions ZQ 7 X
b) Land area designated to building
c) Sewage Disposal Contractor --A
garbage disposal
washing machine i
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 6wner Sign6ture
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
H"'r ov T 6OArme Iry 7;R1t asrfr . A 10fr /,mte,6
ov
17
DCHD (8-82)
OFFICE OF THE DIRECTOR I
Diane Potts
P. 0. Box 11
Advance, NC 27006
Pttbie fgauntg Pealtll Department
Unb game �Iettlt4 Ageing
P. O. BOX 665
Ruckoville, �darth (garolina 27Qz8
April 14, 1987
TELEPHONE
17041 634.5985
Re: Sewage Disposal Installation
and Water, System/Lot #l—Sedgefield
Dear Ms. Potts:
The septic system was installed at the aforementioned address on
February 17,1987. At the time of installation the system met the
requirements of the North Carolina sewage disposal laws. As of this
date, the house has not been occupied; therefore, the system can be expected
to function as designed. The house is served by the county water system.
Please feel free to contact this office, if we could be of further
help
Sincerely,
Robert B. Hall, Jr., R.S.
Environmental Health
RH/wd