P3785 Hwy 601S` DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
'`NOTE: Issued 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 _T� , t .� c.: 4 Date ! ! 7 3785
1 -
Location�^--�-�_ f r i s - t. ► (' :� F r
i
Subdivision Name �''� Lot No. 7 Sec. or Block No.
Lot Size House Mobile Home _ Business Speculation•
No. Bedrooms -2No. Baths rt, No. in Family--
Garbage
amily _
Garbage Disposal
Auto Dish Washer
Auto Wash Machine
Type Water Supply
YES ❑ NO D—
YES ❑.. NO ❑
YES p'`_NO ❑
Specifications for System: J -n -o � ci_L•
*This permit Void if sewage system described below is not installed within 36 months from date of issue
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. or 1:00-1:30 P.M. on day of completion. Telephone Number: 704-634-5985.
Final Installation Diagram:
System Installed byT_< <^y ---b-ek Y —
Certificate of CompletionDate
-t
*The signing of this certificate shall indicate that the system describedJabove 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.
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
R O. Box 665
Mocksvilie, N.C. 27028
SOIL/SITE EVALUATION
ime �1,� S Aw.►�•w.: z�-�(- 2� 7)~ wwt Date
idress V 3 kr A Lot Size
K4�:/4
FArTnRS ARFA 1 ARFA 7 ARTA R AREA A
Topography/ Landscape Position
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S
S
PS
PS
�
PS
_
ct.
U
U
U
Soil Texture (12-36 in.) Sandy,
S
S
S
S
Loamy, Clayey, (note 2:1 Clay)
�7
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,,<-,N PS
PS
U
U
U
U
Soil Structure (12-36 in.)
S
S
S
S
Clayey Soils
rdm.::)
PS
PS
U
U
U
U
SoiY Depth (inches)
«
`rte �5 -�
�o 'rte
PS
PS
LA
U
U
U
U
Soil Drainage: Internal
�
� S
S
1
®
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PS
PS
U
U
U
U
External
Q
S
S
PS
PS
PS
PS
U
U
U
U
Restrictive Horizons
( Available Space
S
S
PS
PS
j
PS
U
U
`U`
U
I Other (Specify)
S
S
S
S
PS
PS
PS
PS
U
U
U<<
U
Site Classification
PS
Uy
U—UNSUITABLE
recommendations/Comments:
S—SUITABLE rPS—Provisionally Suitable
)escribed by !Z�j
•
Title F'��-- �`t'�`-
Date /Z' "?-W
;ITE DIAGRAM
_
ct.
I
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V
LA
1
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3CHO (6-82)
APPLICATION FOR SITE EVALUATION/ IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section
R 0. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone k IV y - V 3 Pd
1. Permit Requested By ` 4 y .SA rv% Business Phone AP Y - 0 7 d'
2. Address O e - y- v. i' i -e
3. Property Owner if Different than Above P v ,'4 A 7 'S'.i „^ j • A �f n
Address t' Y o t g c A 5". Yl,p 11 C;L- 9 a e
4. Permit To: a) Install Alter Repair
b) Privy Conventional Other Type
Ground Absorption
c) Sub -Division Sec. Lot No. ✓
5. System used to serve what type facility: House Mobile Home Business
IndustryOther
b) Number of people
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions
Bed Rooms Bath Rooms Den w/Closet
b) If Business, Industry or Other, State: Number of persons served
What type business, etc. I d d j0
Estimate amount of waste daily (24 hours)
7. Number and type of water -using fixtures:
commodes urinals garbage disposal
lavatory / showers washing machine
dishwasher sinks
8. a) Type water supply: Public Private Community
b) Has the water supply system been approved? Yes No
9. a) Property Dimensions 3 6'0 Y 4,2 O
b) Land area designated to building site
c) Sewage Disposal Contractor
10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve? /V ON `Q
What type?
This is to certify that the information is correct to the best of my knowledge.
I "), — / I — r i �` -�-'4 rbc r H. H C.,
Date Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
�� ►rylt SDS � GP�AS� C�rv�
3 4�
e/i ' y Zra! G� . t * �, z, 3 - - 'i-3
DCHD (6.82)
OFFICE OF THE DIRECTOR
pavie fgountg Pealth Department
anb Fame pealth '�gencv
P. O. BOX 665
C�ocksuille, North (garolintt 27028
December 18, 1984
Mr. Jesse Boyce, Zoning Officer
-- Davie County Courthouse
Mocksville, N.C. 27028
Re: Dwight Sammons Property
Highway 601 South
Mr, Boyce:
The above mentioned property was evaluated by this office on December
17, 1984. The purpose of this evaluation was to,determine the soil/site
suitability for the installation of a ground absorption sewage treatment
and disposal system. Please note that the results of said evaluation were
very favorable, thus this office can forsee no problem with issuing the
required improvements permit to install a sewage treatment and disposal system
for the proposed project.
Feel free to contact my office should we be of further assistance to
you concerning this matter.
'ncerely,
oe Mando, R.S.
Env. Health Coordinator
Davie County Health Department
TELEPHONE
17041 634.5985
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