119 Ada Lane Lot 19DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NPTE ssued 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 Date i 7 r`,10
Location r? 1 1 I- /: -T. T-4- IC{.
Subdivision Name ',G. A ,I, Lot No. i21 Sec. or Block No.
Lot Size t � � , r � House Mobile Home — Business _ Speculation
No. Bedrooms No. Baths a It No. in Family _
Garbage Disposal YES ❑ NO p Specifications for. System: loon
Auto Dish Washer YES p NO p
Auto Wash Machine YES p- NO ❑
Type Water Supply
*This permit Void if sewage system described below is not installed within 36 months from date of issue.
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:
iy
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.:
APPLICATION FOR SITE EVALUATION/ IMPROVEMENTS PERMIT
" Davie County Health Department
Environmental Health Section
P O. Box 665MAR U
Mocksville, N.C. 27028 2 isar
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
// Home Phone'gter- Z(aS-2IOS
1. Permit Requested By (9 Qcino Wl+E37 Je;-( Business Phone Sp. a-
2. Address 6212 MaGSE 4,0fZ PO Nt I -S
3. Property Owner if Different than Above
Address
4. Permit To: a) Install Alter_ Repair
b)Privy_ Conventional Other Type—
Ground Absorption �q
c) Sub -Division Ispel a i.e Sec. Lot No.�l—�
5. System used to serve what type facility: House 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 54f* —4Zi
Bed Rooms_? Bath Roomsfes_ Den w/Closet�—
b) If Business, Industry or Other, State: Number of persons served —
What type business, etc.
Estimate amount of waste daily (24 hours)
7. Number and type of water -using fixtures:
commodes 3 urinals
lavatory showers
dishwasher I sinks —
8. a) Type water supply: Public Private Community
b) Has the water supply system been approved? Yes— No -
9. a) Property Dimensions %S Z r X° (%Z f
garbage disposal
washing machine
b) Land area designated to building site
c) Sewage Disposal Contractor (�JDE�Pct7
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 rrect to the best of my know) g .
3�z( 0'1
D to Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LO AL LAWS
Allow 5 days for processing
Directions to property:
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DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name d,A714 bmju= Date g 2-- k f'
Address Lot Size
FAMORS AREA 1 AREA 2 AREA 3 AREA 4
Topography/ Landscape Position
d)
5)
6)
8)
9)
SS
S
S
PS
PS
PS
U
U
U
U
!) Soil Texture (12-36 in.) Sandy,
®
S
S
S
Loamy, Clayey, (note 2:1 Clay)
PS
PS
PS
PS
U
U
U
U
I) 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
PS
PS
PS
PS
U
U
U
U
Restrictive Horizons
Available Space
S
S
S
S
PS
PS
PS
U
U
U
Other (Specify)
S
S
S
S
PS
PS
PS
PS
U
U
U
U
Site Classification
U—UNSUITABLE S—SUITAB PS—Provisionally Suitable
Recommendations /Comments:
r.
Described by unoe 0 Title
SITE DIAGRAM
Wj
uo
DCHD (6-82)
Date
t3Y.3a'�
,
CONNIE L. STAFFORD, BA, MPH
Health Director
33tt8ie Qlauntg Peult4 33epartment
Unb Fame Pealt4 '�gencg
P. 0.'B0X665
fflachsbiUe, Yarth (Qaralina 27028
August- I7, 1987
Roy Potts
P. 0. Box 11
Advance, NC 27006
TELEPHONE
(704) 6345985
(704) 6345981
Re: Sewage Disposal Installation
& Water System/Gordon Whitney
LIot 19/Springdale
Dear Realtor:
The septic system was installed at the aforementioned address
on June 9, 1987 • At the time of installation, the system met
the requirements of the North Carolina sewage disposal laws. As
of this date, the housa has not been ccupied. Therefore, the system
can be expected to function as designed. This house is served by
the county water system.
Sincerely,
rt B. Hall, Jr., R[[..S.
ronmental Health
RH/wd