P4221 Liberty Church RdDAVIE COUNTY HEALTH DEPARTMENT
I NIMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
RNOTE: iVued 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 Date A 22 1
i7 Ei rtJ
f
117
Location "✓f',;t
Subdivision Name Lot No. Sec. or Block No.
Lot Sizef .���' House Mobile Homey Business Speculation
No. Bedrooms ---� No. Baths No. in Family
Garbage Disposal YES ❑ NO
Specifications„forrSystem:
Auto Dish Washer YES f NO ❑
Auto Wash Machine YES NO -❑�
4�Y
Type Water Supply
`This permit Void if sewage system described below is not installed within 36 months from date of issue.
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
�koq� - Iry 0 1 j
*The signing of this certificate shall indicate that the system d2sC"nbe�i a� �ha een mstalf� incompliance with
the standards set forth in the above regulation, but shall in NO way betaken as a guarantee that the system will function
satisfactorily for any given period of time. -
RECEIVED FEB I p 1986
APPLICATION FOR SITE EVALUATION/ IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section
R 0. Box 665 P
Mocksville, N.C. 27028 Q
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED. ce-u/
1. Permit Requested By
2. Address 12 A h2
Home Phone w% cg= ^ e
Business Phone
3. Property Owner if Different than Above
Address
4. Permit To: a) Install -j, -/Alter Repair
b) Privy Conventional Other Type
r
Ground Absorption
c) Sub -Division Sec. Lot No.
5. System used to serve what type facility: House Mobile Home Business
ther
IndustryOther—
b)
b) Number of people
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions 1211-Ij
Bed Rooms_,— Bath Roomsg— 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 4 - showers ',) -
washing machine
dishwasher sinks
8. a) Type water supply: Public Private Community—tom (!o v w c
b) Has the water supply system been approved? Yes_&LNo
9. 'a) Property Dimensions L1
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? zi/ d
What type?
This is to certify that the information is correct to the best of my knowledge.
Date 67 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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DCHD (8-82)
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A
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. 0. pox 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name � ��/7/ Date 42?
11
Lot Size
FACTr)RS ARFA 1 ARFA 2 AREA 3 AREA 4
1) Topography/ Landscape Position
PS
S
U
S
PS
U
S
PS
U
?) Soil Texture (12-36 in.) Sandy,
Loamy, Clayey, (note 2:1 Clay)
PS
S
PS
U
S
PS
U
1) Soil Structure (12-36 in.)S
Clayey Soils
U
U
U
S
PS
U
U
1) Soil Depth (inches)
(
U
S
PS
U
S
PS
U
i) Soil Drainage: InternalS
PS
S
U
U
S
PS
U
External
Pg
S
PS
U
S
PS
U
i) Restrictive Horizons
Available Space
KS
` S
U
PS
U
S
PS
U
S
PS
U
1) Other (Specify)
S
PS
U
S
PS
U
S
PS
U
S
PS
U
1) Site Classification
U—UNSUITABLE
Recommendations/ Comments:
S—SUITABLE PS—Provisionali Suitable
Described by —,` / Title Date Date
SITE DIAGRAM
1,t1b I k4"-�f rl 6 (y)
DCHD (6-82)