P5570 Liberty Church Rd "-'Fi /"/-- ., i•' •'„- :.,rte_•. y,y:,,..,_c :._zr-+, r . ” L . -..._ -. - .. ", -- .. - r .. -...- .. ... .. .>
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`---"`' DAVIE 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 �G�,E� 17�c�,�Z Date /.,Z ;,(T � NO 55-Ti-)-Ti-)
Location /`
Subdivision Name Lot No. Sec. or Block No.
Lot Size
House Mobile Home Business Speculation
No. Bedrooms r* No. Baths No. in Family__
Garbage Disposal YES .fl NO E3" Specifications for System:
Auto Dish Washer YES Q NO
Auto Wash Machine YES NO �p
Type Water Supply � �� _ •.Jf i�
*This permit Void if sewage system described below is not installed within 36 months from date of issue.
41t
o
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
Certificate of Completion Date
"The signing of this certificate shall indicate that the system described above has been installed ip 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. +'
I
�jlAPPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT '
9 Davie County Health Department
Environmental Health Section
R O. Box 665
4
Mocksville, N.C.27028
} CONST UCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
/its/
/1 /� `� �,Q . Home Phone
1.' Permit Requeste By G i1�Y'"' [[[ `c-e� TSI —`WGyl°/`�' _ Business Phone r 3 375
2. Address 3 Fo Lj n a-K- o V/ll-�
-„ 3. Property Owner if Different than Above /ors- Fo rrt S bi R�h
:a
Address
4. Permit To: a) Install Alter Repair
b) Privy Conventional Other Type
Ground Absorption
c) Sub-Division Sec. Lot No.
5. System used to serve what type facility: House Mobile Homed Business
IndustryOther
.,b) Number of people17� d
`f 6. ar If house or mobile home, state size of home and number of rooms.
House Dimensions
Bed Rooms_Bath Rooms / 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:
commodes urinals garbage disposal O
lavatory / showers washing machine O
dishwasher 4 sinks
8. a) Type water supply: Public Private__ _—Community
b) Has the water supply system been approved? Yes No x
9. a) Property Dimensions '_7 f (Lc_ /z J
b) Land area designated to building site
c) Sewage Disposal Contractor �/
10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve? /Vo
What type?
This is to certify that the information is correct to the best of my knowledge.
Lam.' r4�
Date Owner SignhAure 4Z,
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWSo�-/�-j
Allow 5 days for processing
Directions to property:
TU C,t
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DCHD(6-82) /, - 2O 7
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section.
P. O. Box 665
Mocksville, N.C. 27028
�,,OO SOIL/SITE EVALUATION
Name v
AWL Date
Address Lot Size Z
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position S S S
2) Soil Texture (12-36 in.) Sandy, S
Loamy, Clayey, (note 2:1 Clay)
U
3) Soil Structure (12-36 in.) S
Clayey Soils _ PS
U U
4) Soil Depth (inches)
U U U
5) Soil Drainage: Internal \ S S
db?', k? . - --.0
External S
--��U U U
6) Restrictive Horizons
7) Available Space S S S
–PS PS S
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: z L'-A&."
Described by Title Date
SITE DIAGRAM
UCHD(6.82)
may.
s '
rDavie Caunty Aealty De
arhnent
and .dome Aeakiincy
210 HOSPITAL STREET I P.O.BOX 665
MOCKSVILLE,N.C. 27028
PHONE:(704)634.5985
May 17, 1989
Leonard Realty
34 Town Square
Mocksville, NC 27028
Re: Site Evaluation
601N. to Liberty Church Rd.
Dear Realtor:
On May 16, 1989, as you requested a representative from this office
visited the above mentioned site. The soil was found provisionally suitable
for the installation of a ground absorption sewage system.
If you have any questions, please feel free to contact this office.
Sincerely,
Robert B. Hall, Jr.; R.S.
Environmental Health Section
RH/wd
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Enclosure
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