118 Ada Lane Lot 22✓x0
DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTE: Issued in Compliance With Article II of G.S. Chapter 130a
Sanitary Sewage Systemse Permit Number
Name1 C1 Win ¢ i� e a � C cerin, `� Date-,= � - Z y N2 7 4 8 4
Location r.) <�C tJ �( A ri tt U N r) <e f roZ ? G 0
�•.,�� W fro ti _
Subdivision Name S ��Z�"'L�(X\Lot No. Sec. or Block No.
Lot Size -99"3 House Mobile Home —T Business Industry
No. Bedrooms —.No.:Baths �,),—�Jo, in Family— Public Assembly Other
GarbageeDisposaLr ;°'AYES;[T-ANO [v7 t Specifications for System:
Auto Dish Washer ''`' YES E] NO. -R> ow
Auto Wash Maohine YES 931, NO ❑'`
Type Water Supply
r
'This permit Void if sewage system described below is not installed within 5 years from date of issue.
This permit is subject to revocation if site`plans or the intended use change.
F
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.,
1:00-1:30 P.M. or 4:30-5:00 P.M. on day of completion. Telephone Number: 704-634.5985.
Final Installation Diagram:
System Installed by — ',-��—
F
NdvsR
e9
-
Certificate of Completion - ��i–� Date
'The signing of this certificate shall indicate76t the system described,aabove 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 EVALUATIONAMPROVEMEI
Davie County Health Department
Environmental Health Section
P. O. Box 665
Mocksville, NC 27028
NM 1 7 1924
1. Application/Permit Requested By _� 9Q
Mailing Address Home Phone 98
A d v.9-h/C.e. Ab C, X76 0C, Business Phone 5'/0 -9W -,?33yc
2. Name on Permit if Different than Above
3. Application for:General Evaluation Septic Tank Installation Permit
4. System to Serve: House ❑ Mobile Home ❑ Place of Public Assembly
❑ Business ❑ Industry II ❑ Other ❑ Unknown
5. If house, mobile home: Subdivision Section Lot # 2
❑ Basement/Plumbing .
No. of People
No. of Bedrooms
No. of Bathrooms
3
Dwelling Dimensions -2 6- X ,/-> —
6. If business, industry, place of public assembly, other: Specify type
No. of People Served
No. of Commodes
No. of Sinks _
No, of Urinals
No. of Lavatories No. of Water Coolers
No. of Showers Water Usage Figures
7. Type of water supply: M Public ❑ Private
8. Property Dimensions A C Sewage Disposal Contractor
9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes
If vuc WKAt hmc? -
❑BasementtNo Plumbing
M/Washing Machine
❑ Dishwasher
❑ Garbage Disposal
❑ Community
❑ No
'NOTE: Improvements Permits shall be valid for a period of 5 years from date issued. Improvements Permits are subject to
revocation, if site plans or the intended use change. Effective October 1, 1989.
Directions to Property:
(Rec11�.o'1� Road 4a Govao,, 4o
L04 Al -0 a 'L-
This is to certify that the Information provided is correct to
incurred from this application.
t'1-9
DATE
i_
iv�ddle CI'�1e
best of my' knowledge, and I understand I am responsible for all charges
SIGNATURE
CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY
MUST CHECK ONE: ❑ 1. 1 OWN the property. ❑ 2. 1 DO NOT OWN the property. .
If you checked Box #2, the rest of this form MUST be completed by the owner or a person authorized by the owner:
I hereby give consent to the authorized representative of the Davie County Health Department to enter upon above described
property located in Davie County and owned by
to conduct all testing procedures as necessary to detemm.n said site's suitability for a ground absorption sewage treatment
and disposal system.
DATE SIG ATURE
DCHD (1193)
e27. 10.- :�runLl G: STREET) ry d° e�Qq 2 lV
�.;... GINNy 3o q p8;
LANE. °O:�b;� /o, s 0.804'AC
2 TOTAL' .
s 3q
617.2�
CID '60 75.00 175. 0
0
WILLIAM,.A ELLIS _ o R/W- 03935°d �° %S
0B 99 PG 1 ,amu mPw' a91p8or�;W 9 2p, IISrQd N86.4 GIN. .
:..r ,y 82 9s�.� s N Y
3O EXIST► c: 2a 68"r36c/t..b'Orc67.92�
�. NG ASE
413:31 MENT Q.o `" (8 �o,� 5�f"-Ch ' I i25.00
TOTAL N f .1 rn N8d°45' I 1
/?66° 13� 3 E w> 86°13� 36 w - `24AC.- �Q W 1
r 12.47.`383.56 TOTAL v N 84° 53..44„
RIDDLE I 132.47 Q 0) 0 182,70 � 1 }
PG. 301 3 1 fr0.�R� 118.62 Q P rr17 i I
w q �, 0.561 AC.
�, Crd - w
M:h.. WN a 22 43A N =
�..� 47' n - - N v' W w - �� r7 � V I _
"' N. 23 _ °'
to
cu -,o - °in N.: c� o oc N -84 53. 44•�W - N - . n
`O K) 248.19 O <D L) 0186.89' ^ ' 0.901 Q('_Z
�n :Z 0.768 AC_ 21 �� 0.561 AC, " » 0.914 AC!
2 m h u; ` 0
_ ^ -::>o n o Z
CD
10'UTILITY '— N
EASEMENT ti - ` z�0
I
5675-18.03- - I rI SEMENT FOrt ? -
ly -132.53- 1 I \ T_�p0>RARY'..CUL-DE-SAC-
N 86° 02' 25" N 87° J ' --115.0 ttt -----=193.450 0.o'-- -
W 55 59•• W\ - �-'- 60.94 -
;:� t S 8 rJ 5 4 � W 10 UTI Lir UTILITY EASE
150.56 TOTAL49OA6 TOTAL -��
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P,E41L S GORDOiv SR.
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DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
c ��
Name -� ja- Date
Address Lot Size
FAr:rnac ARFA i ARFA 2 AREA 3 AREA 4
Topography/ Landscape Position
4)
5)
6)
S
S
S
PS
PS
PS
PS
U
U
U
U '
!) Soil Texture (12-36 in.) Sandy,
U
S
S
S
Loamy, Clayey, (note 2:1 Clay)
PS
PS
PS
PS
U
U
U
U
1) Soil Structure, (12-36 in.)
S
S
S
Clayey Soils
PS
PS
PS
PS
U
U
U
U
Soil Depth (inches)
S
S
S
PS
PS
PS
PS
U
U
U
U
Soil Drainage: Internal
�
S
S
S
PS
PS
PS
PS
U
U
U
U
External
S
S
S
S
PS
PS
PS
U
U
U
U
Restrictive Horizons
r) Available Space
S
S
PS
S
PS
S
PS
U
U
U
U
3) Other (Specity)
S
PS
S
PS
S
PS
S
PS
U
U
U
U
3) Site Classification
U—UNSUITABLE�ltABL PS—Provisionally Suitable
Recommendations/ Comments:
w _
Described by Title
;SITE DIAGRA �oitD
32-S'3
DCHD (6-62)
Date
Lar *L
21
3S•GL