421 Madison Road Lot 13~� = DAVIE COUNTY HEALTH DEPARTMENT T��
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION (/
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*NOTE: Issued in Compliance With Article II of G.S. Chapter 130a
Sanitary Sewage Systems 1 Permit Number
Name ;.. /��c,,,r� �Y� dSro�G1%�/� Date % 911 ND 6069
r�
Location Y0L111 41 K/O i//-3
Subdivision Name l /6.y./ (Q/ook Lot No. Sec. or Block No.
,
Lot Size House i' 'Mobile Home _ Business Speculation
No. Bedrooms No. Baths No. in Family
Garbage Disposal YES ❑ NO p"'
E:]Specification System:
Auto Dish Washer YES NO c/
Auto Wash Machine YES�'NO'❑
Type water Supply ('d _ .?'DO Xs Kxv
*This permit Void if sewage system described below is not installed
This permit is subject to revocation if site plans or the intended us
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:
System Installed by
Certificate of Completion • Date70
'The signing of this certificate shall indicate that the system described above has been installed in compliance with
the standards set forthin 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 Y
Environmental Health Section � /�
P. O. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED..
Home Phone _ 07
Rusiness Phone
Permit Requested By
>. Address
3. Property Owner if Different than Above
Address -a
4. Permit To: a) Install_ Alter— Repair_
Op
1+4
b) Privy_ Conventional_ Other Type—
14A -P
V14
-PA�RC$l,
, Ground Absorption
1449
A4 (+
-�APCE.�
c) Sub -Division Sec. Lot No:
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, tate size of home and number of rooms.
House Dimensions APP aw QCL4�
Bed Rooms Bath Rooms 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 ater-using fixtures:
commodes urinals I
lavatory showers
dishwasher ' sinks I
8. a) Type water supply: PublicPrivate Community
b) Has the water supply
9. a) Property Dimensions
been approved? Yes_ No_
b) Land area designated to building site —
[OZ.oc C3) s'02ac
toz-6Z(E)to ai;'
garbage disposal
washing machine
c) Sewage Disposal Contractor
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
Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section. l
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name \; Date
Address Lot Size
FACTORS AREA 1 AREA 9 AREA R Aare A
1j Topography/ Landscape Position
9)
a
®
S
S
PS
PS
PS
PS
U
U
U
U
2) Soil Texture (12-36 in.) Sandy,
S
S
S
S
Loamy, Clayey, (note 2:1 Clay)
0
I
PS
PS
U
U
U
3) Soil Structure (12-36 in.)
S
S
S
S
Clayey Soils
(9
A
PS
PS
U
U
U
3) Soil Depth (inches)
V
S
S
fsS
PS
PS
PS
U
U
U
fU
i) Soil Drainage: Internal
S
S
S
S
PS
PS
' ~
U
U
U
External
ra�
S
S
PS
PS
PS
PS
U
U
U
U
i) Restrictive Horizons
Available Space
S ,
S
PS
S
PS
U
U
i) Other (Specify)
S
S
S
S
PS
PS
PS
PS
U
U
U
U
Site Classification
U -UNSUITABLE
Recommendations/Comments:
S—SUITABLE PS—Provisionally Suitable
Described by �.���� S Title cf�> Date
SITE DIAGRAM
DCHD (e 82) - 1
/�of/3
^ Dade Cnunfy NealfFi Deppaitnenf
and Nuke Aealflf Ayency
210 HOSPITAL STREET I P.C. BOX 885
MOCKSVILLE. N.C. 27028 .. -
PHONE:(704)834.5985.
August 27, 1990
Potts Realty
Attn: Diane Potts
P. 0. Box 11
Advance, NC 27006
Re: Sewage System Installation
Stonybrook/Lot 13
Dear Realtor:
The septic tank system that serves this residence was designed,
inspected and approved by this office on July 20, 1990.
With proper maintenance and use it should function properly.
Sincerely,
Robert B. Hall, Jr., R.S.
Environmental Health Section
RH/wd