P6131 Liberty Church Rd DAVIE COUNTY HEALTH DEPARTMENT 0 ,
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTE:Issued'in Compliance With Articl�,�of G.S.Chapter 130a
_ -Sanitary Sewage Systems _ Permit Number
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Name C� s ��t �� ? (�Rti to t���c�Date _ y 0,
Location � —
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Subdivision Name Lot No. Sec. or Block No.
Lot Size {Z House Mobile Home _ Business Speculation
No. Bedrooms a` No. Baths j No. in Family
Garbage Disposal YES ❑ NO 0,- Specifications for System:
Auto Dish Washer YES ❑ NO [
Auto_Wash Machine YES 0 NO' ❑ �
Type Water Supply
*This permit Void if sewage system described below is not installed within 5 years from date of issue.
This permit is subject to revocation if site plans or the intended use change. "
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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 C\A�
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v'
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Certificate of Completion � �_ 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.
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section o
P. 0. Box 665
Mockaville, NC 27028 �►/
U
1 . Application/Permit Requested By04
Mailing Address 1� J rlU t �'e- O� / 5-5
Home Phone "/"/sa Business Phone
2. Name on Permit if Different than Above
3. Property Owner if Different than Above
4. Application/Permit For : General Evaluation S/Tank Installation
S. System to Serve: House bile Home Business
L Industry u Other Unknown
6. If house, mobile home: Subdivision Sec. Lot#
No. of People o Dwelling Dimensions
No. of Bedrooms Basement/Plumbing
No of Bathrooms ` Basement/No Plumbing
Washing Machine (J' Dishwasher C) Garbage D:isposai
7. If business, industry, other: Specify type
No. of People Served No. of Sinks
No. of Commodes No. of Urinals
No. of Lavatories No. of Water Coolers
No. of Showers
S. Type of water supply: V Public Private Q Community
9. Property Dimensions 120 61 dzl,<- 4ez
10. Sewage Disposal Contractor
11 . Do you anticipate additions/expansions of the facility this system is
intended to serve? Yes ,"o
-01If yes, what type?
;NOTE: Improvements Permits shall be valid for a period of . 5
years from date issued. Improvements Permits are subject
to revocation, if site plans or the intended use change .
Effective October 1, 1989.
This is to certify that the information provided is correct to the
best of my knowledge, and I understand I am responsible for all
charges incurred from this appl tion.
Mo -P-A -
Date Si nature
Directions to Property :
ye
10 AWO
�I� C
DCHD (10-89)
" DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation l' q
NAME ���`'� �'z`� R DATE EVALUATED T - I O
ADDRESS A rcr.Q _ PROPERTY SIZE
PROPOSED FACIILTY ��`� LOCATION OF SITE ht Q.r2��. �• ��
Water Supply: On-Site Well I/ Community Public
Evaluation By:�,'�, A-AugerBoringPit Cut
FACTORS 1 1 2 3 4
Landscape position Z,
Sloe R -1�'
HORIZON I DEPTH
Texture group C_
Consistence - T1 F 1
Structure (' V
MineralogyI ; I
HORIZON II DEPTH t<, ' 6'' 6 to "
Texture groupC. C_
Consistence
Structure k �3
Mineralogy
HORIZON III DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS Ss SS S s 5�
RESTRICTIVE HORIZON — —
SAPROLITE —
CLASSIFICATION �S
LONG-TERM ACCEPTANCE RATE 3.S I, •S - 6 a
SITE CLASSIFICATION: Q .5° EVALUATED BY: c
LONG-TERM ACCEPTANCE RATE: 3 `� LI D OTHER(S) PRESENT: .w�.
REMARKS: —\ 2:�� _� 'Z!'s4 '
LEGEND
Landscape Position
R-Ridge S-Shoulder L-Linear slope FS-Foot slope N-Nose slope
CC-Concave slope CV-Convex slope T-Terrace FP-Flood plain H-Head slope
Texture
S-Sand LS-Loamy sand SL-Sandy loam L-Loam SI-Silt
SICL-Silty clay loam, SIL-Silty loam CL-Clay loam SCL-Sandy clay loam
SC-Sandy clay SIC-Silty clay C-Clay
CONSISTENCE
Moist
VFR-Very friable - FR-Friable FI-Firm VFI-Very firm EFI-Extremely firm
Wet
NS-Non sticky SS-Slightly sticky S-Sticky VS-Very Sticky
NP-Non plastic SP-Slightly plastic P-Plastic VP-Very plastic
Structure
SC-Single grain M-Massive CR-Crumb GR-Granular ABK-Angular blocky
SBK-Subangular blocky PL-Platy PR-Prismatic
Mineralogy
1:1, 2:1, Mixed
Notes
Horizon depth - In inches
Depth of fill - In inches
Restrictive horizon- Thickness and inches from land surface
Saprolite - S(suitable), U(unsuitable)
Soil wetness - Inches from land surface to free water' or inches from land surface to soil colors
with chroma 2 or less
Classification - S(suitable), PS(provisionally suitable), U(unsuitable)
LTAR - Long-term acceptance rate - gal/day/ft2
DCHD(01-901