116 Livengood Rd R
DAVIE COUNTY HEALTH DEPARTMENT'S IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTE:Issued in Compliance With Article II of G.S.Chapter 130a
Sanitary Sewage Syste s Permit Number
Name'' � 9 Ay els' .411 i. Date N2 61
Location 61� '<W'�'
ti
Subdivision Name Lot No. Sec. or Block No.
Lot Size House Mobile Home ��''�� Business __ Speculation
No. Bedrooms c?2 No. Baths No. in Family — F. _
Garbage Disposal YES ❑ NO Specifications for System: ,
Auto Dish Washer YES NO ❑ �
Tv�-
- Auto Wash Machine YES NO ❑ �r�����/�
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.
Improvements permit by /dzz ZZ
*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 bye. .�4
�1
Certificate of Completion f /� 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 cCcD AUG Z 1
Environmental Health Section R
P. 0. Box 665
Mocksville, NC 27028
1 . Application/Perm it Requested By n �f�1�Y7Lo
Mailing Address 61 o- 'Z'Zny. 446 1"A]LGf` a NC, a-)DD(P
Home Phone `7� 1 'g ' �y�� Business Phone 91q - Ca CSU
2. Name on Permit if Different than AboveR
3. Property Owner if Different than Above
4. Application/Permit For : lC] General Evaluation S/Tank Installation
5. System to Serve: House ► Mobile Home 0 Business
LL Industry u Other 0 Unknown
6. If house, mobile home: Subdivision Sec. Lot#
No. of People Dwelling Dimensions
No. of Bedrooms Basement/Plumbing
No. of Bathrooms Basement/No Plumbing
Washing Machine Dishwasher 0 Garbage Disposal
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
8. Type of water supply: C Public Private a Community
9. Property Dimensions 'IDS:E.
10. Sewage Disposal Contractor
11 . Do you anticipate additions/expansions of the facility this system is
intended to serve? Yes No
If 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 application.
44-90
Date Signature
Directions to Property :
of
r
DCHD (10-89)
DAYIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
NAME DATE EVALUATED
ADDRESS PROPERTY SIZE
PROPOSED FACIILTY
LOCATION OF SITE ��/ll��.Ce'
Water Supply: On-Site Well Community Public
Evaluation By: Auger Boring / Pit Cut
FACTORS 1 2 3 4
Landscape position J_ J .L
Slope % 6
HORIZON I DEPTH Y y
Texture group S'
Consistence r0-
Structure
MineralogX
HORIZON II DEPTH `I
Texture group
Consistence
Structure
Mineralogy
HORIZON III DEPTH
Texture grouR
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE / ,
SITE CLASSIFICATION: zvs� EVALUATED BY:
LONG-TERM ACCEPTANCE RATE: Cl OTHER(S) PRESENT:
REMARKS:
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 fine 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
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