540 Liberty Church Rd (3) 4W-
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 �P m,Qs �. ��� �c��s Date $ ' I L! N2 668:-A
Location 3 N .� —
��v ► to _
Subdivision�ame Lot No. Sec. or Block No.
Lot Size 0 Hduse Mobile Home Business Speculation
No. Bedrooms �' No. Baths No. in Family__�—
Garbage Disposal YES 0 NO p�y ;,,Specifications.for System:0
Auto Dish Washer.., YES p ' 'NO {y
Auto Wash Machine YES NO 'fl
Type Water Supply _—
*This permit Void if sewage system described belowds not installed.within 36'months from date of issue.
a
r
2.,
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
V �I
I FA1-
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Certificate of Completion Date t
"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 665 REEEWo AUS 14 09
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone
1. Permit Requested By C S 'T' M/j s Business PhoneG NL
2. Address — R�e- K g-53 /10 C_ks V,I le– /U C �--`)d 7-�8'
3. Property Owner if Different than Above
Address
4. Permit To: a nstall Alter Repair
b) Privy Conventional 'Other Type
Ground Absorption
c) Sub-Division Sec. t No.
5. System used to serve what type facility: House Mobile Home Business
Industry er
b) Number of people f „
6. ay If house or mobile home, state size of home and number of rooms.
House Dimensions 4L
Bed Rooms ,--2 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:
commodesurinals /L-� garbage disposal /I/O ✓s`�P�
lavatory showers washing machine_��
dishwasher d`7�`�i sinks
8. a) Type water supply: Public Private Community
b) Has the water supply system been approved? Yes No
9. a) Property Dimensions /d
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?
What type?
Thi
is t 7 ,certify that the information is correct to the best of my knowledge.
i --'Z—
Date Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR CO PLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
to o t tj � t. �t F�- L,�t�.� C�• tZQ � �`o t r,^,• � - a►- R•9h'�-- tv'cL..-c�
DCHD(6-82)
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DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section.
P. O. Box 665
Mocksville, N.C. 27028
1 SOIL/SITE EVALUATION
Namey es Y�° 'h�'RS Date
Address A`"r\e Lot Size 0 v�
fr '
FACTORS AREA 1 AREA 2 AREA 3 AREkk 4
1) Topography/Landscape Position S
PS PS
U U U U
2) Soil Texture (12-36 in.) Sandy, S S CESS
Loamy, Clayey, (note 2:1 Clay) C
U �tf� U
3) Soil Structure (12-36 in.) S S S
Clayey Soils P ® 4� �b
U U U U
4) Soil Depth (inches) S S S S
P§ 4�m> �
5) Soil Drainage: Internal S S --q43<� � PS q43
U U U U
External & �-S�, zt
P "�
U U U U
6) Restrictive Horizons
7) Available Space
PS PS PS PS
U U U U
8) Other (Specify) S S S S
PS PS PS PS
9) Site Classification
U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable
Recommendations/Comments: ` ��-""� `�' �kuA ''' —�'
NA
Described by - �`�'' Title
SITE DIAGRAM
DCHD(6.82)