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2644 Liberty Church Rd y _ yr-.�.. �..-, r. y�vw..w...v'�.>...a_v _ r - t. '-• a i • v. .. .,t. 4A�_... d. DAVIE COUNTY HEALTH DEPARTMENT 1 d t, IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION *NOTE: Issued in Compliance with G.S.of:.North. Carolina Chapter 130 Article 13c Sewage Treatment and Disp\osal Rules (10 NCAC '10A .1934-1.1968) Permit Number Name tia b .\ �e�l \� U O �2. Date —i! - - NO 5 7 t;2 Location i:) E Subdivision Name Lot No. Sec. or Block No. - Lot Size �� a-QS &n "House Mobile Home _ _ Business _____�Sp u�'icon No. Bedrooms A No. Baths_ A No. in Family r- 1. Garbage Disposal YES p NO [ ' Specifications for System: Auto Dish Washer YES ❑ NO n o Auto Wash Machine YES [/ .NO ❑ Type. Water SuPPIY - LaJ. ,`�: a __ c ..,.��. ' ;rte - •' ��c, y *This permit Void if sewage system described below is not installed within �-8'months from date of issue. —n I z 0 a , -S— Improvements permit by1 . .,. . .., _ , �•�•� *Contact a representative of the Davie County Health Department for final inspection of this system between 8:30- 0:30 A.M. or 1:00-1:30 P.M. on day of compliption. Telephone Number: 704-634-5985. Final Installation Diagram: System Installed by ` 1 / pC) Ce ificate of Completion �'` Date -� *The signing of this certifZC�� dk e that the system,described above has been installed-in compliance with the standards set forth irk- above egvlation, but*,shall in NO way be taken as a guarantee that the system will function satisfactorily for any gi en period,c�f time: at- APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT s Davie County Health Department Environmental Health Section 9 P. 0. Box 665 M©cksville, NC 27028. R�CEIVEQ 1 . Application/Permit!!Req-u•ested By z/- t1-/f1/Y . 'dDD� _ Mailing Address �0l� /',�//Y`�'.S77, lq/Gy 1&4�1 Home Phone �'�`� Business Phone 2 . Name on Permit if Different than Above S4�r'`-;Or 3. Property Owner if Different than Above S41'•`£ 4. Application/Permit For : 0 General Evaluation S/Tank Installation 5 . System to Serve: 0 House E' Mobile Home Business . 0 Industry C Other 0 Unknown 6. If house, mobile home: Subdivision - Sec. Lot# No. of People Dwelling Dimensions Xro No, of Bedrooms L Basement/Plumbing No. of Bathrooms+— C Basement/No Plumbing 0 Washing Machine 0 Dishwasher 0 Garbage Disposal 7 . I.f business, industry, other: Specify type No. of People Served No. of Sinks No. of Commodes No. of Urinals No. of Lavatories No. of Water Coolers f No. of Showers 8. Type of water supply: 0 Public Private 0 Community 9 . Property Dimensions o? 10. Sewage Disposal Contractor- 11 . ontractor11 . Do you anticipate additions/j%po ansions of the facility this system is intended to serve? 0 Yes If yes, what type? *NOTE: Improvements Permits shall be valid for a period of 5 years from date issued. Improvements Permits are subject li to revocation, if site plans or the intended use change. Effective October 1, 1989. 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 Directions to Property: DCHD (10-89) r 41 a DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section. P. 0. Box 665 Mocksville, N.C. 27028 SOIL/SITE EVALUATION Name Date // Address �a/� /���— CCN /�' Lot Size FACTORS ARE 1 AREC2 AREA.D AREA 1) Topography/Landscape Position S S S PSi� dUS ' U s 2) Soil Texture (12-36 in.) Sandy, S S S S Loamy, Clayey, (note 2:1 Clay) S U U U 3) Soil Structure (12-36 in.) S 4F Clayey Soils PS (�_ P5=' U U U 4) Soil Depth (inches) SS PS CPS U U U 5) Soil Drainage: Internal S PS ck U U U U External S U U U 6) Restrictive Horizons � Y y � � � ► � ` � � � I v G tom/ (� 7) Available Space Sg\ � (� U—\ PS U U 8) Other (Specify) S S S S PS PS PS PS 9) Site Classification S S U—UNSUITABLE S— BLE PS—Provisionally Suitable Recommendations/Comments: - Described by Title Date SITE DIAGRAM US 0 r DCHD(6-82) • DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section, R O. Box 665 Mocksville, N.C. 27028 SOIL/SITE EVALUATION l q Name �' g+-�-e� �` Date Address Lot Size FACTORS AREA 1 AREA 2 AREA 3 AREA 4 1) Topography/Landscape Position S S S S PS PS PS PS U U U U 2) Soil Texture (12-36 in.) Sandy, S S S S Loamy, Clayey, (note 2:1 Clay) PS PS PS PS U U U U 3) Soil Structure (12-36 in.) S S S S Clayey Soils PS PS PS PS U U U U 4) Soil Depth (inches) S S S S PS PS PS PS U U U U 5) Soil Drainage: Internal S S S S PS PS PS PS U U U U External S S S S PS PS PS PS U U U U 6) Restrictive Horizons 7) Available Space S S S S PS PS PS PS U U U U 8) Other (Specify) S S S S PS PS PS PS U U U U 9) Site Classification U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable Recommendations/Comments: Described by Titles�� SITE DIAGRAM DCHD(6-82)