1196 Liberty Church Rd t/
DAVIE COUNTY HEALTH DEPARTMENT �r,
�- IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
•NOTE:Issued in Compliance With Article II of G.S.Chapter 130a
Sanitary Sewage Systems / �i -� %/, Permit Numbers ''�
Name &d _ — Date �� N_ 8000
tl"
Location _-� /� �. '/" '✓ ✓. �r ` j -
Subdivision Name Lot No. Sec. or Block No.
t
Lot Size House — Mobile Home Business —_ Industry
No. Bedrooms 2- —.No. Baths —_ No. in Family _ Public Assembly Other
Garbage Disposal YES ❑ NO ❑ Specifications for System:
Auto Dish Washer YES ❑ NO
Auto Wash Ma^hine YES ❑ 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
ATTENTION: YOUR SEPTIC SYSTEM CONTRACTOR MUST SEE THIS PERMIT/LAYOUT BEFORE INSTALLING THIS
SYSTEM.
Improvements permit by X&IL
*Contact a representative of the Davie County Health Department for final Inspection of this system between 8:30-9:30 A.M.,
1:00-1:30 P.M. or 4:30-5:00 P.M. on day of completion.Telephone Number: 704.634-5985.
Final Installation Diagram: System Installed by
Certificate of Completion �'' �`:�� Date .5
'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.
Ca ,
�(� APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERM L;l4 6��1,'c '
+-� Davie County Health Department
Environmental Health Section N 0 V 8 1 9
P. O. Box 665 I
Mocksville, NC 27028 71ox27 . .. '
1. Application/Permit Requested By
Mailing Address l L; hP c A-U �'-k u c c,k. no-O Home Phone
�K s 1 Ie N, C- D-2 0 ,43 Business Phone
,
2. Name on Permit if Different than Above. R e r`-
3. Application for: ❑General Evaluation 25eptic Tank Installation Permit
4. System to Serve: ❑ House obile Home ❑ Place of Public Assembly
❑ Business ❑ Industry ❑ Other ❑ Unknown
5. If house, mobile home: Subdivision Section Lot #
❑ Basement/Plumbing
No. of People ❑ Basement/No Plumbing
No. of Bedrooms 5��ashing Machine
No. of Bathrooms ishwasher
Dwelling Dimensions 0 d ❑ Garbage Disposal
6. If business, industry, place of public assembly, 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 Water Usage Figures
7. Type of water supply: 0-Ou—blic ❑ Private ❑ Community
8. Property Dimensions o2 I �— �-� • Sewage Disposal Contractor
9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes o
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.
Directions to Property:
a _
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.
DATE SIGNATURE
CONSENT FOR SITE EVALUATION TO BE,DONE ON ABOVE DESCRIBED PROPERTY
Fandd
ECK ONE: ❑ 1. 1 OWN the property. �. I DO NOT OWN the property.
ked Box#2, the rest of this form MUST be completed by the owner or a person authorized by the owner:
ve consent to the authorized representativ of the Da tj2s-q'�'
County Health Department to enter upon above described
cated in Davie County and owned by ,
all testing procedures as necessary to determine said ite's suitability for a ground absorption sewage treatment
al system.
--')) -� a
DATE SIGNATURE
DCHD(1/93)
DAVIE COUNTY HEALTH DEPARTMENT
-� Environmental Health Section
Soil/Site Evaluation
NAME `�/`�'� DATE EVALUATED
ADDRESS PROPERTY SIZE r�G
PROPOSED FACIILTY LOCATION OF SITE
Water Supply: On-Site Well Community Public
Evaluation By: Auger Boring Pit Cut
FACTORS 1 2 3 4
Landscape position .C, .4-
Slope %
4-Sloe %.
HORIZON I DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH Tell"I
Texture group C_ G
Consistence
Structure Slims Shit Sill
Mineralogy
HORIZON III DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION S S
LONG-TERM ACCEPTANCE RATE ,Q /
SITE CLASSIFICATION: !� ' �' EVALUATED BY: ILLI,
LONG-TERM ACCEPTANCE RATE: / 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 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
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Davie County Nealtk Department
and NOh7e Aa11 .gye1h y
210 HOSPITAL STREET I P.O. Box 665
MOCKSVILLE.N.C. 27028
PHONE:(704)634.5985
November 17, 1994
Kathy B. Allen
1196 Liberty Church Rd.
Mocksville, NC 27026
Re: Site Evaluation
Liberty Church Road/2 1/2 Acres
Dear Ms. Allen:
As requested, a representative from this office visited the aforementioned
site on November 16, 1994. Based upon the information provided on the
application for a site evaluation and after the evaluation was completed, the
site was found to be provisionally suitable for the installation of an on—site
sewage disposal system.
If you have any questions, please feel free to contact this office.
Sincerely,
IQ�- _4�4071
Robert B. Hall, Jr. , R.S.
Environmental Health Section
RH/wd
Enclosure
DAME COUNTY HEALTH DEl?�ARTMENT
n Environmental Health*Secton
PO Box 848/210 Hospital Street
Mocksville,NC 27028
Phone:.(336)751-8760
ON-SITE WASTEWATER CERTIFICATION FOR DWELLING
(Check One) REPLACEMENT❑ ,REMODELING ❑ RECONNECTION ❑
r
Name n n t�*% e �' Q-r�_ Phone Number: (Home)
Mailing Address: (Work)
n .
Detailed Directions To Site: b cnn �1
GL. ' W eIA-
Property Address:
Please Fill In The"Following Information About The Existing Dwelling:
T Of Dwelling: �/C
Name System Installed,Under.—
'Number
. _ 9S
Date System Installed(Month/Day/Year) `y` Number Of Bedrooms: Number Of People:
;Is The Dwelling Currently Vacant? Yes( No 6 If Yes,For How Long?
Any Known Problems?Yes,❑ • NoLq,,,,-lf Yes,Explain:
Please Fill In The Following Information About The New,Dwelling: } �
Type Of Dwelling_t0,UUQ--WtPL Number Of Bedrooms: P Number Of People:
:Requested By: Date Requested: - 9
(S_gnatur
w For Environmental Health Office'Use Only
Approved D�iisapproved;❑ n
Comments:
Environmental Health Specialist Date hy10,3
*The signing of this form by the Environmental.Heart 'Staff Is in no way intended,nor should be taken as a
guarantee(extended or limited) at the on-site wastewater system will function properly for any given period of time.
Payment: Cash❑ Chec Money Order❑.# A unt: $ U Date:
v3
Paid By: Received By:_
°Account #: Invoice #• -7 `�'