1438 Fork Bixby RdDAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMEN Ts PERMIT AND CERTIFICATE OF COMPLETION
*,NOTE: Issued in Compliancewj�f - .S. of North Carolina Chapter 130 'Article 13c
Sewage Treatraetr d Disposal Rules (10 NCAC 10A .1934-.1968) Permit, Number
Name Date
.ter
Y
Location . `/4
Subdivision Name Lot No. Sec. or Block No.
Lot Size fil G House ��Mobile Home _ Business __ Speculation
No. Bedrooms _ No. Baths __ No. in Family _
Garbage Disposal YES ❑ NO E] Specifications for SysteTr _ ✓,,f
Auto Dish Washer YES NO ❑ .r l-- 'f'�/
Auto Wash Machine YES (] NO ❑ ,�' L Yj
Type Water Supply
"This permit Void if sewage system described below is not installed within
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:
Installed by
;Iad
i
Certificate of Completion _�!Lo 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.
64 E to Fork Community - Left onto Fork Church Road. Roughly 2 - 2 1/2 miles
Property to be tested joins property with Grey House with large pines in front
yard. "The Millers" on wooded sign hanging under mailbox. This house is.on
the right -across the road you may note a yellow house with split rail fencing
Park in -drive way of grey house since the --driveway is not complete to new
property. Adjoining the garden, is the wooded lot. There is a pasture at the
back of the yard. Follow the fence on the right side of the yard next to the
new property - down across the -creek and up the hill - the location of the
house is marked with orange flourescent tape.
RECEIVED
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.
Home Phone 99d'- S-s'S3
1. Permit Requesed'ByytQ byG_"' �G�yn�1� � tZ&2i Business Phone a
2. Address 0--,2 Q/ -x '�lv 'Ad
3. Property Owner if Different than Above
Address
4. Permit To: a) Install k" Atter Repair
b) Privy Conventional Other Type
Ground Absorption
c) Sub -Division Sec. Lot No.
5. System used to serve what type facility: Housed Mobile Home Business
Industry Other
b) Number of people 3
6. a) If house or mobile home, state size of home and number of rooms.���'�
House Dimensions a$ X 70 p�QUG�I�
Bed Rooms 3_,— 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 water -using fixtures:
commodes 3 urinals garbage disposal
lavatory -3 showers z washing machine /
dishwasher sinks
8. a) Type water supply: Public Privateer Community
b) Has the water supply system been approved? Yes No
9. a) Property Dimensions
b) Land area designated to building site
c) Sewage Disposal Contractor ✓ %'% ti��' r` / ,
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.
lo`�0-d'6 2
Date Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
64 EC�ii vt ch fecal. - �� �'� ► �2c 0� c �,1� 1�' — Ga/t�u� '�71�t�;�e�
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1DCHD (6-82)
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DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
R O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name �,� Date
Address Lot Sizes ; l9
FACTORS ARFA 1 AREA 9 ARFA 3 ARCA A
1) Topography/ Landscape Position
S
PS
S
S
PS
S
PS
U
U
U
2) Soil Texture (12-36 in.) Sandy,
Loamy, Clayey, (note 2:1 Clay)
�S
—
S
PS
S
PS
U
U
U
U
3) Soil Structure (12-36 in.)�
Clayey Soils
(,RrS�
S
PS
S
PS
`t�T
U
U
1) Soil Depth (inches)
S
PS
S
PS
U
`�
U
U
i) Soil Drainage: Internal
S
PS
S
PS
U
U
External
S
PS
S
PS
S
PS
U
U
i) Restrictive Horizons
Available Space
PS
U
0
PS
U
S
PS
U
S
PS
U
I) Other (Specify)
S
PS
U�
S
PS
U
S
PS
U
S
PS
U
1) Site Classification
�J ,
U—UNSUITABLE S—SUITABLE e-' PS—Provisionally Suitable
Recommendations/Comments:
Described by —Title�/U Date
SITE DIAGRAM
DCHD (6-82)
Ddi e County NealtFr De arfinent
and Name NealtFr Ayency
210 HOSPITAL STREET/ P.O. BOX 665
MOCKSVILLE, N.C. 27028
PHONE: (704) 634-5985
December 17, 1987
Charles David Miller
Rt. 2, Box 210
Advance, NC 27006
Re: Sewage System Installation
Location Fork Church Rd.
Mr. Miller:
The septic tank system that serves your residence was designed,
inspected and approved by this office on September 28, 1987.
With proper maintenance and use it should function properly.
Sincerely,
Robert B. Hall, Jr., R.S.
Environmental Health
RH/wd