P2508 Howardtown Rdw� C DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
Note. Issued in Compliance with G.S. of North Carolina
Chapter 130—Article 13c.
Permit Number
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Subdivision Name Lot No. Sec. or Block No.
Lot Size Z -'= �� e ' House Mobile Home _tom/ Business Speculation
No. Bedrooms No. Baths No. in Family 6
Garbage Disposal YES p NO p
Specifications for System: j0'-3 7;�r.rr:
Auto Dish Washer YES E] NOp d r/
Auto Wash Machine YES Q NO�j
Type Water Supply U3 -r b t- D - ILe.o �;r� Ce,°Jcr2 5 "1
`This permit Void if sewage system described below is not installed within 36 months from date of issue.
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Improvements permit by Cr-^iA-
*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:
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System Installed by '" ?.
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Certificate of Completion��' Date I -
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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.
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DAVIE COUNTY HEALTH DEPARTMENT
PERCOLATION TEST RESULTS
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LOT DIAGRAM
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DAVIE COUNTY HEALTH DEPARTMENT
ENVIRONMEt7TAL HEALTH SECTION
� P.O. BOX 57 .,
• MOCKSVILLE, N.C. 27028
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(704) 634?ZS985
STATEMENT FOR
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SEPTIC TA14K INYROVEMENTS- PERMITS AND/OR SITE EVALUJATIOil'S
NAME ,�i �'t'! 7� ems', S �_ ', t'� U �-� � � � OL .. DATE��7j
ADDRESS !-- ' �`Jk , �' , i K. i '�Cyq �1 SPE 4,ViJT 1Q0.''4 ✓
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EXPLANATION OF CHARGE <I - f Z r V A- L, V A 71 ti z �.
AMOUNT� 1�1. SANITARIAN`;,
PLEASE REMIT THE ABOVE AMOUNT OF RECEIPT OF THIS STATEMENT.
*NOTICE: Evaluation (s) can not be completed until payment is received.
Improvements Permit(s) can not be issued until payment is received.
STATE OF NORTH CAROLINA
COUNTY OF DAVIE
• Merritt Stephenson
The undersigned, James Boyd Stephenson $ Sandra , owner of property located
at Howardtown Road ("the site") and described in instrument
recorded in Book 111 at page 153, Davie Public Registry, hereby acknowledges that he
applied to the Department of Health, Davie County for a permit to install a septic
tank sewage disposal system on the site; the Department evaluated the site for suita-
bility for such a system in accord with the regulations promulgated by the North Car-
olina Commission for Health Services as 10 NCAC 10A .1900 et seq; that the Depart-
ment classified the site as unsuitable and an appropriate permit was
issued by the Department.
The undersigned further acknowledges that the proper design, construction and
maintenance of such septic tank system is his responsibility and that neither the De-
partment nor its officials, employees, or agents warrant or guarantee that the said
system installed pursuant to the permit issued by the Department will function in a
satisfactory manner for any given period of time, or that the Department, its offic-
ials, employees or agents assume any liability for damages, consequential or direct,
which are caused, or which may be caused, by a malfunction of such system.
This document shall be placed on the public records of the REgister of Deeds of
Davie County and indexed therein under the Grantor Index in the names or names of the
undersigned, and the foregoing acknowledgements shall henceforth be binding on all
persons claiming any right, title or interest in the site.
And the undersigned further agrees for himself, his heirs and assigns, that he
shall idemnify and hold harmless the Department and its successors, as well as Davie
County, for any damages or other claims of any person or persons whatsoever arising
out of the installation, operation, or failure, of said septic tank system.
And the undersigned further agrees for his heirs and assigns that, in the event
any septic tank system installed under authority of the aforesaid permit fails to per-
form adequately, in any respect, he will take whatever measures are required to corr-
ect same; or if such is impossible, he will discontinue use of said system immediately
Use of the singular masculine pronoun forms herein shall be deemed to also in-
clude the plural and feminine forms as the context may require.
This 18th day of July , 19 80
STATE OF NORTH CAROLINA - u Seal)
COUNTY OF DAVIE
I, Jessie S. H' ar Public for said Count and State do
�$��� .Boyd Stephan��� Y Y �
hereby certify that Sandra Merritt Stephenson personally appeared before me this
date and acknowledged the due execution of the foregoing instrument.
WITNESS my hand and notarial seal, this 18th day of July 19 80.
N�qary Public
STATE OF NORTH CAROLINA My Commission Expires 12-9-80
COUNTY OF DAVIE
I, , a Notary Public for said County and State, do
hereby certify that personally came before me this day and
acknowledged that he is of , and that by
authority duly given and as the act and deed of said corporation, the foregoing in -
strument.was signed in its name by its , sealed with its corpo-
rate seal and attested by as its
WITNESS my hand and notarial seal, this day of 19
Notary Public
My Commission Expires
NORTH CAROLINA, DAVIE COUNTY
The foregoing certificate(Q of Jessie S. Hinkle
Notary Public(sj of Davie County is
(arc) certified to be correct. This instrument was presented for registration this
18th day of July , 19 80 at 9:00 A.M., 1Y.M. and duly recorded in the office
of the Register of Deeds of DAVIE COUNTY, North Carolina in Book 111 Page 241
This the 18th day of July A.D. 19 80
BY:
J.K. Smith, REGISTER OF DEEDS UMM, DEPUTY REGISTERUP-DEEDS