1308 Liberty Church Rd (2) -+s�—'A: i ,- "' x�.. ''T=:, 'y l .[•'�.. 5d x ruS. N''..e,y.i�+;t,i V`zl*S" �'tisi}:s. tik f{ tt n.-;;"n •- >:� r� �f -?'-!:i J ;;.
DAVIE COUNTY HEALTH DEPARTMENT `, a
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTE:Issued in Compliance With Article II of G.S.Chapter 130a
Sani�ry Sewage Systems Permit Number
Name ( !: /z i/,, �/.r�J"'? Date 71,62
y
( U 2
Loc/a�i9n� —
Subdivision Name Lot No. Sec. or Block No.
Lot Size House Mobile Home _ Business Speculation
4 �
No. Bedrooms .No. Baths f No. in Family —
r
Garbage Disposal YES ❑ NO ❑
Specifications for System:
Auto Dish Washer YES ❑ NO E] / j
f
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department REMOVED�
Environmental Health Section
P. O. Box 665 I�
Mocksville, NC 27028 HAY
1. Application/Permit Re ted By r�Lc/
Mailing Address
Home Phone / Business Phone
2. Name on Permit if Different than Above
3. Application/Permit for: ❑ General Evaluation Septic Tank Installation ;
4. System to Serve: ❑ House V Mobile Home ❑ Place of Public Assembly
❑ Business ❑ Industry ❑ Other ❑ Unknown
5. If house, mobile home: Subdivision Section Lot #
❑ Basement/Plumbing
No. of People 2 El Basement/No Plumbing
No. of Bedrooms Ly Washing Machine
No. of Bathrooms ❑ Dishwasher
Dwelling Dimensions X �a ❑ 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: w Public ❑ Private ❑ Community
8. Property Dimensions b` aae- a� Sewage Disposal Contractor � im/a-ti
9. Do you anticipate additions/expansion of the facility this sytem 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.
Directions to Property:
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.
/993
DATE NA U RE
CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY
MUST CHECK ONE: + 1. I OWN the property. ❑ 2. I DO NOT OWN the property.
If you checked Box#2, the rest of this form MUST be completed by the owner or a person authorized by the owner:
I hereby give consent to the authorized representative of the Davie County Health Department to enter upon above described
property located in Davie County and owned by '
to conduct all testing procedures as necessary to determine said site's suitability for a ground absorption sewage treatment
and disposal system.
DATE �SIGTURE
DCHD(12-90)
f 1
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
NAME ,y _!�9/ 5•,l DATE EVALUATED
ADDRESS PROPERTY SIZE � >>�
PROPOSED FACIILTY LOCATION OF SITE
Water Supply: On-Site Well Community Public
Evaluation By: Auger Boring Pit Cut
FACTORS 1 2 3 4 6 7
Landscape position 4 �- L
Sloe Z 02
HORIZON I DEPTH
Texturegroup
Consistence
Structure
Mineralogy
HORIZON II DEPTH r t
Texture group
Consistence
Structure
Mineralogy
HORIZON III DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE
SITE CLASSIFICATION: EVALUATED BY: IG3✓��
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-Finn 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 HEALTH DEPARTMENT
< A` IMPROVEMENT PERMIT and OPERATION PERMIT
IMPROVEMENT PERMIT
**NOTE** This improvement permit DOES NOT authorize the construction or installation of a septic tank system or any wastewater
system. AN AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION must be obtained from this Department prior to the
construction/installation of a system or the issuance of a building permit.
(In compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
NAME 19+ 4s PROPERTY ADDRESS /,pe 0—A'uf `i C(- DATE
LOCATION
SUBDIVISION NAME LOT NUMBER SEC./BLOCK NUMBER
RESIDENTAL SPECIFICATION:-BUILDING rTYPE: #:BEDRODM8 f #,_BA
P! ,,,i# OCCUPANTS GARBAGE DISPOSAL: Yes
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes/No
LOT SIZE TYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD) ^t5 NEW SITE REPAIR SITE &---
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH LINEAR TT. �3r
_
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
**#THIS PERMIT IS SUBJECT TO REVOCATION IF SITE PLANS OR THE INTENDED USE CHANGE. YOUR WASTERWATER SYSTEM CONTRACTOR MUST
VSEE..THIS PERMIT BEFORE INSTALLING THE SYSTEM.
r
IMPROVEMENT 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 THE DAY OF INSTALLATION. TELEPHONE # IS (704) 634-8760.
OPERATION PERMIT SYSTEM INSTALLED BY
67
r
AUTHORIZATION NO. OPERATION PERMIT BY HCl/ DATE
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMP(.IANCE WITH
ARTICLE 11 OF G.S. CHAPTER 130A, SECTION! .1900 "SEWAGE TREATMENT AND DISPOSAL SYSTEMS-, BUT SHALL IN NO WAY BE TAKEN AS A
GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY,GIVEN PERIOD OF TIME.
DCHD 10/95
DAVIE COUNTY HEALTH DEPARTMENT
44
IMPROVEMENT PERMIT and OPERATION PERMIT
IWROVEMENT PERMIT.
**NOTE+* This improvement permit DOES NOT authorize the-construction or installation of a septic tank system or any wastewater
system. AN AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION must be obtained from this Department prior to the
construction/installation of a system or the issuance of a building permit.
(In compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
Al
NAME ,•• / PROPERTY ADDRESS �-/I�2I / G1 Zf� �`�Ad_� �� j�"
( ��/ V DATE i
LOCATION
SUBDIVISION NAME LOT NUMBER SEC./BLOCK NUMBER
RESIDENTAL SPECIFICATION:'BUILDING TYPE' S& BEDR�MIS, #. BATHS _L,•'t OCCUPANTS GARBAGE DISPOSAL: Yes
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes/No
LOT SIZE TYPE WATER SUPPLY / DESIGN WASTEWATER FLOW (GPD) NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH ✓ �LINEAR FT.
OTHER 16,-
REQUIRED SITE MODIFICATIONS/CONDITIONS:
***THIS PERMIT IS SUBJECT TO REVOCATION IF SITE PLANS OR THE INTENDED USE CHANGE. YOUR WASTERWATER SYSTEM CONTRACTOR MUST
:'SEE THIS PERMIT BEFORE INSTALLING THE SYSTEM.
I RROVEMENT 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 THE DAY OF INSTALLATION. TELEPHONE # IS (704) 634-8760.
OPERATION PERMIT SYSTEM INSTALLED BYijs
AUTHORIZATION NO. ����� OPERATION PERMIT BY /�'' DATE
—z
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE WITH
ARTICLE 11 OF G.S. CHAPTER 130A, ,SECTION .1900 "SEWAGE TREATMENT AND DISPOSAL SYSTEMS", BUT SHALL IN NO WAY BE TAKEN AS A
r.', 'GUARANTEE THAT THE`SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN_ PERIOD OF TIME.
i/Xo
Davie County Health Department
e ENVIRONMENTAL HEALTH SECTION
P.D. Box 665
Mocksville, N.C. 27028
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
(Issued in compliance with Article 11 of
G.S., Chapter 130A, Wastewater Systems)
***This Authorization For Wastewater System Construction must be issued by the Davie County Environmental Health Section prior to
issuance of any Building Permits. This Form/Authorization Number should be presented to the Davie County Building Inspections
Office when applying for Building Permits.***
T.1 ��-� --- AUTHORIZATION NUM9ER
NAME /�-f �r�" ,.✓E'1i.9.�.tY
DATE ����/ � _ 0 2
NAME ON IMPROVEMENT PERMIT (If different than above)
SITE LOCATION
COMMENTS/CONDITIONS ON AUTHORIZATION TO CONSTRUCT WASTEWATER SYSTEM
***NOTICE*** THIS AUTHORIZATION FOR WASTEWAT SYSTEM CONSTRUCTION IS VALID FOR A PERIOD OF.FIVE (5) YEARS.
Y-41
ENVIRONMENTAL WXTH 9ECIA IST DATE
DCHD -10[95
' ., w'L •.._.•. •a .,,« Kk-yl r.,, c S z :taw.w,..{� a 62 i
- Y DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
APPLICATION FOR IMPROVEMENT PERMIT(REPAIR)
NAME (. _.�GI/Y� ������✓� PHONE NUMBER
ADDRESS /Z
a O SUBDIVISION NAME
,4�m 'Ile LOT#
DIRECTIONS TO SITE
DATE SYSTEM INSTALLED NAME SYSTEM INSTALLED UNDER
TYPE FACILITY NUMBER BEDROOMS NUMBER PEOPLE SERVED
TYPE WATER SUPPLY l rI SPECIFY PROBLEM OCCURRING
DATE REQUESTED j� y" /� INFORMATION TAKEN BY
This is to certify that the information provided is correct to the best of my knowledge,andthat I erstand 12, responsib for all charges incurred from this application.
SIGNATURE OF OWNER OR AUTHORIZED AGENT °
C 4F
Rev.1/93 1