6124 Liberty Church RdDAVIE COUNTY HEALTH` DEPARTMENT M -
IMPROVEMENTS . PERMIT AND CERTIFICATE OF COMPLETION = . —
*NOTE: Issued in Compliance withG.S. iof North Carolina Chapter 130, Article 13c - -
If
.Sewage Treatment and Disposual Rules (10 NCAC 10A..1934-.1968) Permit Number. .
Name ' �a Q �- �-, s�: �a , �Il� cin N—ate Date 20 D1 'R 4705 -
-Location
. Sub 'ivision Name j� .Lot No _ Sec. or Block No.
Lot Size HOUSE II Mobile Home _� Business __ Speculation
No. Bedrooms ��- Nq. Baths I,.. No. in Family
Garbage Disposal = . YES ,'❑ N ii :�l Specifications for System:
Auto Dish Washer, '.;r YES ❑ : N
II
-Auto Wash Machine' YES' Q>` N ❑ a`
Type Water Supply_ II
"This permit Void if sewage `system described below is not installed within 36 months from date of issue.
Improvements ' permit'by
P Y
*Contact a representative of the DaV.ie County Health Department for final inspection of this system between 8:30-
9:30 A. M. or 1:00-1:30 P.M. on d ly o� ' completion. Telephone Number: 704-634-5985.
Final Installation "Diagram: System Installed by
i
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!)
lk
r APPLICATION FOR SITE EVALUATION/ IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section
R O. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
1. Permit Requ
2. Address 51
Home Phone a "YV/
3. Property Owner if Different than Above &W
Address Sa 7n(-- a S --4 1 �- ;?-
4. Permit To: a) Install-1ffAlter 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 I,,'- Business
IndustryOther
b) Number of people 3
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions Z!
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
lavatory
urinals
showers
dishwasher `'w sinks
garbage disposal
washing machine
8. a) Type water supply: Public Private ✓ Community. `7,4%4"
b) Has the water supply system been approved? Yes No
9. a) Property Dimensions/ 2cegg�—
b) Land area designated to building site
c).Sewage Disposal Contractor' '' `��✓c/t�
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.
DateOwner Signature
k
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
j
077
DCHD (6-82)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name Ci����� Date��
Address Lot Size
FACTnRB
AR ARRA 9 1 AREA .1 AQGA A
1) Topography/ Landscape Position
SS
S
PS
PS
U
U
U
U
2) Soil Texture (12-36 in.) Sandy,
Loa Clay ; (note 2:1 Clay)
S
PS
S
PS
U
U
U
U
3) Soil Structure (12-36 in.)
Clayey Soils
S
S
PS
P5
PS
PS
�• U
U
U
U
f) Soil Depth (inches)
P
PS
S
PS
S
PS
U
U
U
i) Soil Drainage: Internal
�
�S1
S
PS
S
PS
U
U
U
U
External
S
PS
S
PS
U
U
U
U
i) Restrictive Horizons
d)
d
Available Space
S
PS
�---PS
PS
PS
U
U
U
U
1) Other (Specify)
S
PSS
S
S
PS
S
PS
U
U
U
1) Site Classification
S
—1
)
U—UNSUITABLE S—SUITABLE �P�—Provisionally Suitable
Recommendations/ Comments:
Described by �� �-��Titles Date
SITE DIAGRAM
w
/n
DCHD (6-82)