514 Liberty Church Rd = DAVIE COUNTY HEALTH DEPARTMENT
- IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION /6
s *_NOTE:Issued in Compliance With Article I I of G.S.Chapter 130a a
Sanitary Sewage Syste s Permit Number
Name Date 3 ` ^� ' N° 5878
Location ' �.tr3?:�+, ��= ,.ice Ca�C?� -.. L. t�c_�� ^ `,) \\�✓ \`� `�
In�� � 1" � t.`;�... �r+.�.13�_C•��,L \ (��-� .^Ct�1� �Ccr, cl�_�3,� ``\' N'..°���
Subdivision Name of No. Sec. or Block No.
Lot Size � n ~.{� 1 C House Mobile Home L� Business Speculation
No. Bedrooms J No'.Baths No. in Family
Garbage Disposal YES ❑ NO pJ Specifications for System:
Auto Dish Washer,, YES ❑ NO a 0 o
Auto Wash Machine YES V 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.
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-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
p
a Certificate-of Completion Date 4
*The igning of this cern Cate shall indicate that the system describes 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.
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
4 Davie County Health Department
Environmental Health Section a
P. 0. Box 665 p r1AR
Mockaville, NC 27028 R'-C, :
1 . Application/Permit Requested By A )(gkn-nJ NnA'P—
Mailing Address /r o (/1 a-tt kaeU . 29004
Home Phone �9-0u) e,?, - 3(o Business Phone q - NO 3:6300A
2. Name on Permit if Different than Above �'^
3. Property Owner if Different than Above C, / �',[/t,dA s�
4. Application/Permit For: 0 General Evaluation (9/S/Tank Installation
5. System to Serve: 0 House I/Mobile Home 0 Business
0 Industry u Other 0 Unknown
6. If house, mobile home: Subdivision Sec. Lot#
No. of People C3 Dwelling Dimensions 0� S X q4'
No. of Bedrooms Basement/Plumbing
No. of Bathrooms Basement/No Plumbing
(Washing Machine 0 Dishwasher 0 Garbage Disposal
7. If 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
No. of Showers
8. Type of water supply: Public 0 Private 0 Community
9. Property Dimensions o'!00 X a�0
10. Sewage Disposal Contractor
11 . Do you anticipate additions/expansions of the facility this system is
intended to serve? 0 Yes gKNo
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.
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.
&L'q(-) Zzxi xx')
Date Signature
Directions to Property :
(SOI NORTH +o LIMIRTki O-VAURCH Rd . k0peRTy 1S
(�PPRoX , 1 m\LC pN +he, RIGHT, C �e--rw e e-m 0� R ic.K�ome.S)
DCHD (10-89)
- DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section,
P. O. Box 665
Mocksville, N.C. 27028
CS
\ SOIL/SITE EVALUATION
Name C V,o`N �• y e Date
Address S Lot Size U 0 k O a
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position ��
`�J
U U U
2) Soil Texture (12-36 in.) Sandy, S S S
Loamy, Clayey, (note 2:1 Clay) (2�5 PS
-1) 7�
U U
3) Soil Structure (12-36 in.) SS
Clayey Soils ep,
C�' PS
U
4) Soil Depth (inches) S
5) Soil Drainage: Internal S S
CIUD
P l PSS PS
External <�
U U
6) Restrictive Horizons
7) Available Space S
PS PS PS PS
U U U U
8) Other (Specify) S S S S
PS PS PS PS
U
9) Site Classification
U—UNSUITABLE S—SUI \ PS—Provisionally Suitable
Recommendations/Comments:
Described by Title S Date
SITE DIAGRAM
S
�0
DCHD(5-82)