2622 Liberty Church Rd (3) �. ...n. -.r.a._:'„y:. �"--�'r._.w+.n..•.^vl Jml0.s.'•�'�^...�*•&'�„�°ry.. •'a'•'•y. � _'.4ryi :�,s: ` y,r.,�•. .Fd'•s v`-•r-- •,�.- .,..� - --- ._
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DA �VIE COUNTY HEALTH DEPARTMENT
PROVEMENTS PER IT' 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 Date 4535 '.
311
Location
Subdivision Name �I Lot No. Sec. or Block No.
Lot Size HOUSE 'Mobile.Home _ Business Speculation
'No. Bedrooms No. Baths I No. in Family __
Garbage Disposal. YES': NO
II
Sp e i{ tions for System: ,
Auto Dish Washer YES ❑ NO 0 (�
Auto Wash Machine YES []' N' ❑ �i 3,�1 X07
Type Water Supply 1�/y �I --- '®
.'This permit Void if sewage, system described-below `s not installed th• 36 months from date of issue.
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 d iy of completion. Telephone Number: 704-634-5985.
. I
Final Installation Diagram: Syste Installed by G i
Lj
Certificate of Com••letion Dat y�
"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'.
� APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section
P. O. Box 665 f
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone j
1. Permit Reque ed By �� �" Business Phone
2. Address
3. Property Owner if Different than Above 27.260�
Address
4. Permit To: a) Installlf:��lter Repair
b) Privy Conventional Other Type
Ground Absorption
c) Sub-Division Sec. Lot No.
5. System used to serve what type facility: Housel&r Mobile Home Business
Industry Other
b) Number of people
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions
Bed Rooms— Bath Rooms Den w/Closet
Zge
b) If Business, Industry or Other, State: Number of persons served
What type business, etc.
Estimate amount of waste daily (24 hours) /G� -
7. Number and type of water-using fixtures:
commodes urinals garbage disposal
lavatory. / showers washing machine
r
dishwasher sinks
8. a) Type water supply: Public Private `✓ Co munity
b) Has the water supply system been approved? YesNo
9. a) Property Dimensions
b) Land area designated to building site
C) Sewage Disposal Contractor - F
10. Do you antict
ny additions or expansions of the facility this sewage system is intended to serve?
What type?
This is to certify that the information is correct to the best of my knowledge.
Date Owner Signa
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
f /
C
G'
DCHD(6-82)
r
s `i DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name Kvrvrut,& 10&-t 'a& Date
Address Lot Size
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position S S
PSS PS
2) Soil Texture (12-36 in.) Sandy, S S S S
Loamy, Clayey, (note 2:1 Clay) PS -&S& P
SPS
U
3) Soil Structure (12-36n.) S S S S
Clayey Soils PS PS
U & U
4) Soil Depth (inches) S S S S
S
OU
PS
V U
5) Soil Drainage: Internal S S S S
PS PS PS
U
External S S
p PS y
<EP PS
U 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 U� ' U . U ,.
9) Site Classification 5- C/• -
U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable
Recommendations/Comments:
Described by / Title Date
SITE DIAGRAM
L::;7lam'
DCHD(582)
,r.
„A-
pulaie (gountU Health Department
ana 'Home pealth �Benru
P. O. BOX 665
Iacksbil[c, �Zarth (fara[ina 27028
OFFICE OF THE DIRECTOR TELEPHONE
October 13, 1986 1704) 634.5985
Mr. Kenneth Perdue
1011 Jefferson Street
High Point, NC 27260
Mr. Perdue:
Please find enclosed a permit to install a septic tank system
at your residence on Liberty Church Road in Davie County. The
existing tank is approved as is but nitrification line will need
to be added.
You have 30 days upon receipt of this letter to have the
system installed.
If you have any questions, feel free to call.
Sincerely,,
60-('&/-Ig ;Katz,.g .
Robert B. Hall, Jr. R. S.
Environmental Health
RBHJR:sg
Enclosure