2468 Liberty Church RdDAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTE: Issued 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 1 �/) ` 7/ ,.r i.1 "I
f�,. r 4 3
Location r c�,�;% - f/, `-%'�.;`
Subdivision Name Lot No. Sec. or Block No.
Lot Size -t House Mobile Home Business Speculation_
No. Bedrooms No. Baths No. in Family 9
Garbage Disposal YES ❑ NO p—
Specifications for S�stem:
Auto Dish Washer YES Ep NO ❑
Auto Wash Machine YES NO ❑ i
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.
Firfal Installation Diagram:
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System Installed by
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Certificate of Completions' - Data' 7-�� -
'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.
1. Permit F
2. Address
APPLICATION FOR SITE EVALUATION/ IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section
P 0. Box 665 RECEIVED NOV 2 4 '1886
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Howard Real
Home Phone 704-63413754
s_ TNr, Business Phone 704--634-3538
3. Property Owner if Different than Above Maw' Gentle Steelman
Address Route #2, Box 154, Ashhoro,N,C;
4. Permit To: a) Install x Alter Repair
b) Privy Conventional x Other Type
Ground Absorption
c) Sub -Division Sec. Lot No.
5. System used to serve what type facility: House__x_ Mobile Home Business
Industry Other
b) Number of people 2
6. a) If house or mobile home, state size of home and number of rooms. U^T_DFQ 00'1Tr'RAC7 TO
House Dimensions Double ivMe inolikle. hook,'-' John :Pelts
Bed Rooms 3 Bath Rooms 2 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:
l commodes 2 urinals
lavatory 2: showers
dishwasher
sinks
8. a) Type water supply: Public X Private Community
b) Has the water supply system been approved? Yeses No
9. a) Property Dimensions See Map attacW66,
b) Land area designated to building site
c) Sewage Disposal Contractor To be: determined
garbage disposal
washing machine 1
10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve? no
What type?
This is to certify that the information is correct to the best of my knowledge.
11-21.,86 c__4A�c
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
R O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name Date
Address Lot Size
FACTORS ARFA 1 ARFA 9 ARFA 3 ARFA A
2
3
5
6)
8)
) Topography/ Landscape Position Ste, S S S
PS PS PS
U U U U
) Soil Texture (12-36 in.) Sandy, S S S
Loamy, Clayey, (note 2:1 Clay) —Z)PS PS PS
U U U U
) Soil Structure (12-36 in.) S S S P�
Clayey Soils PS PS PS
U U U U
d) Soil Depth (inches) S S S
k:> PS PS PS
U U U U
) Soil Drainage: Internal S S S
PS PS PS
U U U
External S S S
PS PS PS
U U U
Restrictive Horizons
Available Space S S S
S PS PS PS
U U U U
Other (Specify) S S S S
PS PS PS PS
/411 U U U
9) Site Classification i
U—UNSUITABLE
Recommendations/Comments:
S—SUITABLE ` PS—Provisionall
Described by 9 1 l Title Date Jf�
SITE DIAGRAM
DCHD (6.82)
U—UNSUITABLE
Recommendations/Comments:
S—SUITABLE ` PS—Provisionall
Described by 9 1 l Title Date Jf�
SITE DIAGRAM
DCHD (6.82)