P5472 Liberty Church Rd - 1 .••.fir-'. .l _ .r:. .w.- ..• .._ ..<).
� - DAVIE COUNTY HEALTH DEPAR ME_NT ��'
`"IMPROVEMENTS PERMIT AND CERTIFICATE 'OF COMPLETION. 3 '
*NOTE: lssued�ln Compliance with G.S. of North Carolina Chapter 130 Ariicle 13c --
�ewage Treatment and Disposal Rules (10 NCAC 10A .1934-.1968) Permit Number
Name 933 aeii Date � zS 7 N2 o472
Rt 4.7 BOX 1 ' . 27028
a t:
Location a qq
f 1• ra t' �: L . �^`i ii 31+.3 z\4
Subdivision
Subdivision Name Lot No. Sec. or Block No.
Lot Size _ House Mobile Home _ Business Speculation
•l
No. BedroomsNo. Baths t No. in Family
Garbage Disposal YES .0 -NO1. Specifications for,System:
Auto Dish Washer - YES 0 NO � / '•��• 'r: •,ate.
Auto Wash Machine YES p' NO 0
Type Water Supply
*This permit Voi". sewa a ystem described below is not installed within.36 months from date of issue. ti
Vs U4"`�
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t
Improvements permit bye^-r. �• �`n
*Contact a representative of the Davie County Health Department for final inspection of this system between 8:30-
9:30 A.M. or 1:00-1:30P.M. on day of completion. Telephone Number: 704-634-5985.
Final Installation Diagram:' System Installed by �.n� !1 -a.��-��
F,�
Lit L`
1. . . F 1
Certi ' to pi do Date `
"The signing of this certificate shall indicate that the system aeen-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 vs
Davie County Health Department rr��11 AR 1
Environmental Health SectionrV�V
P. O. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone
1. Permit Req ester' By Business Phone
2. Address
3. Property Owner if Different than Above _
Address _
4. Permit To: a) Install Alter Repair
b) Privy Converitional cher Type
Ground Absorption
c) Sub-Division Sec. Lot No.
5. System used to serve what type facility: House Mobile Home_1'Business
Industry Other
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.
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 /' 7/'§� R ergs
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?
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:
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DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
\ SOIL/SITE EVALUATION
Name. o. 3 N �� \ Date
Address S Lot Size �J
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position aS
S C�p 1 PS
U U U
2) Soil Texture (12-36 in.) Sandy, C-S�/
Loamy, Clayey, (note 2:1 Clay) �� (gyp. PS �$ P P
U U U
3) Soil Structure (12-36 in.) S
Clayey SoilsPS PS PS PS
U
U
4) Soil Depth (inches)
PS P PS
U
5) Soil Drainage: Internal S PS PS
<Z:p <� S
U
External S
P PS 416
U U
6) Restrictive Horizons
7) Available Space
PS S 6PS A�
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:
Described by �- Title aDate
SITE DIAGRAM
DCHD(6-82)