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266 Edwards Rd (2) _ �,!' {� 4� " -� � • � ��J�/Z�//ZP,S �(L'��/�S `�'`'v � �, "_� �:(il. ; � „ ,�,-,c� . • DAVIE COUNTY HEALTH DEPARTMENT � IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION , .- _. � , --"NOTE:Issued in Compliance With Article II of G.S.Chapter 130a Sanitary Sewage Systems Permlt Number . , , _ ;� r ;, �f ... No 7958 Name �`i' � �','' „ .'%l�� , i'� % 1_ Date � _ � �y`. � . � Location — _ j , ,/ ,—/` J, `f, 'f - r- F f—_ f i . , `r" � � /��✓" f< r . _ .,- l. E. - i: Ir_ Subdivision Name Lot No. Sec. or Block No. Lot Size ._,--�f— _ House _ Mobile Home �''�_ Business __ Industry No. Bedrooms �` _ No. Baths _—�'_— No. in Family •�� _ Public Assembly Other Garbage Disposal YES ❑ NO p'' Specifications tor System: Auto Dish Washer YES ❑ NO [.�' ,,, ., . Auto Wash Ma^hine YES [,�-�'�NO [] `� � t `.;� �� , Type Water Supply --- �� . : 1�' -------- ��• r_.,.j ;3 f_•' . - 'This permit Void if sewage system described below is not instalied within 5 years from date of issue. This permit is subject to revocation if site plans or the intended use change ATTENTION: YOUR SEPTIC SYSTEM CONTRACTOR MUST SEE THIS PERMIT�LAYOUT BEFORE INSTALLING THIS SYSTEM. � '�______-----------_. J ` _� . _ . ... r �`� ..�..�...'�..+.�.`� . t � . . �...�..�...�..�� . Improvements permit by —_Jj�"''`� 'Contact a representative of the Davie Counry Health Department for final inspection of this system between 8:30-9:30 A.M., 1:00-1:30 P.M. or 4:30-5:00 P.M.on day of completion.Telephone Number: 704-634•5985. Final InstaUation Diagram. System Installed by ��br��m ��J ------�---- � j�„ ��,, � 1' , � Certificate oi Completion _�__ Date �� l�� _ 'The signing ot 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 tor any given period of time. « � �� ,f ' ' APPUCATION FOR SITE EVALUATION/IMPROVEMENTS �-•— p ��/�^t `,,,p�' Davie County Health Department �� ' �� 1�� ; �V r Environmental Heaith Section � � ' P. O. Box 665 � �4 � Mocksville, NC 27028 F�...: _.., _ .. .!1:_�Jir1 1. Application/Permit Requested By �Z� � f�;'JI�f:�xi�.iiV Mailing Address 7 9 S Ti�n��-+ l�ic+� 1'�d/ Home Phone �� 2- - 5 �6 � /12e''L�L'-Si:/`c /te Z 7�Z�' Business Phone � Z' s s(�s 2. Name on Permit if Different than Above 3. Application for: ❑General Evaluation �ptic Tank Installation Permit 4. System to Serve: ❑ House LJ'Mobile Home ❑ Place of Public Assembly ❑ Business ❑ Industry O Other ❑ Unknown 5. If house, mobile home: Subdivision Section Lot # ❑ BasemenUPlumbing No. of People � ❑ BasemenUNo Plumbing No. of Bedrooms � p�lNashing Machine No. of Bathrooms � � ❑ Dishwasher Dwelling Dimensions �y� �O� ❑ 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: ❑ Public C�Private ❑ Community 8. Property Dimensions 5 a.c�n Sewage Disposal Contractor 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes C�'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: � � `�f � -°'� -� �`�'��n �`r� �.� .��.�..�- �„� � �,�g. �;.,u„�-,` .s�.9 .1�-a.�i �. .�.�V'J� . r � �,. � d ,�s-��. .r�.�� " ..� ��,,- ��--�9-0 �� .S�-4.�� 9.� �-�- n-�-�-�- This is to certify that the information provided is correct to the best of my know�edge, and I understand I am responsible for all charges incurred from this application. 3-a �f -9 s -��-��-�- �� DATE SIGNATURE 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 Co ty ealth Department to enter upon above described property located in Davie County and owned by ��-Q, � to conduct all testing procedures as necessary to determine said site's suitability for a ground absorption sewage treatment and disposal system. 3 -a`1- 9 5 �(�.�.�-L. -�3�-�- DATE SIGNATURE OCHD(1/93) � • •s' ` � , , . , DAVIE COUNTY HEALTH DEPARTMENT � � Environnlental Health Section , ' Soil/Site Evaluation NAME � �/✓ DATE EVALUATED --�1�/��' ADDRESS PROPERTY SIZE �� PROPOSED FACIILTY ,�� -!7� LOCATION OF SITE �-E'��r d`' Water Supply: On-Site Well � _ Community Public Evaluation By: AugerBoring � Pit Cut FACTORS 1 2 3 4 Landsca e osition G L L Slo e 7. �2 �2 Z HORIZON I DEPTH Texture rou Consistence Structure Mineralo HORIZON II DEPTH 3 G -t Texture rou C, � L Consistence � Structure / /� i - Mineralo HORIZON III DEPTH Texture rou � Consistence Structure Mineralo HORIZON IV DEPTH Texture rou Consistence Structure Mineralo SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CL?,SSIFICATION � LOyG-TERM ACCEPTANCE RATE � , i SITE CLASSIFICATION: EVALUATED BY: / LDNG-TERM ACCEPTANCE RATE: � , OTHER(S) PRESENT: REMAR KS: LEGEND Landscape Position R-Ridge S-Shoulder L-Linear slope FS-Fooc 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-Si1tY �;lay loam SIL-Silty loam CL-Clay loam SCL-Sandy clay loam SC-Sandy clay SIC-Silty clay C-Clay CONSISTENCE Moist VFR-V+�-y friable FR-Friable FI-Firm 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 ,iC--Sin�;le grain M-Massive CR-Crumb GR-Granular ABK-Mgular blocky SBK-Subangular blocky PL-Platy PR-Prismatic Mi neralagy 1:1, 2:1, Mixed Notes Fiorizon 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 wate�' 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(O1-9o1 ■��■��■�■��■�■��■��\�� ■ ■��■ ■■ ■��_��N��n��_�� _��■ ■�■��■ ��■��■��■��■■��■ ■��■�� ■ ��■ ................................�........�.�..................... .......................................... . ..................... .................................................................. .........................................................■■....... ........................................... ....... ............. ..................................■■.....■C....■■..�....■....■■.. ..........................................■..._...._ ............. ■��■��N�� ■ ��■ ■\��/��■ � �/�� ■�■��■��■ ■��■�■�� ■ ■ �� ■��■■��■ ■��■■�■�■��■■��■��■��■� ��■�� ■��■�� ■��H�� iiiiiiiiiiiiii=iiiiiiiiiii�iiiii=iiiiiiii�iii=�i� =iii��iiiiin�iiii ■��■��■��■_��■■��■��■��■�� ■��■ ■��■��■��■��■��=�u�■��■■ ■��■��■��■�/� ■��■��N��■��■��■ ■��■��N�� ■ ■ ��H�� ■�■��■��■��■�■��■�■��■��■��■��■ ■��■��■��■�■��■��■■�� N�� ■��■ ■ �� ■��■■��_��■��■��u=��■��_� C:C:::C:::C:::::::::::::::::::::::.:::::::::: .::.C:C:::::.::�':■C ■��■�/��■■��\��n/��■��Hv��N�u�■�� ■��■��■��■��\�� ■■ ■ ■��■�� ■��■�■��■��N��■��M��■��\�� ■ �� \��/ ............................................... .■_...�......�� ■��■�■��■��■��■��■��■��N ■ �� ..............................................��_ �.._.........0 .■.■.■■■....■■..■.■.....■................ ..... . .. .■ ....■.. .........................................�....... ..C....=s....... iiiiiiiiiiiiiiiiiiiii�iiiiiiiiii�iii�i'�''w�'ii� C��'�'iiiiii� ■��NN��o,N��■ �� /��■��\■� ■ ��■� ■ �J �� ■��MnG7��s�� ■ �� ■\�■��■��I�� ■�� ■� � �� ■..�■�■�� ri�� %�■ � ��u u.■ ■ �■ �� ■��■N�� ■��■■■�� ■��■��H��■��■■��■ �N ■ ■��■�� ■��■�� u� �� ■��■ ��vN�� - ■ �� N��■� ��/�N�I�� ■ �� u��vU��N��uu�l�� 1 �� ■�� ■��\��■� ��I�� N�� ■ �� \��u�%��%�� ■ �� a■■�� ■��■■��_��■au��q�� •... ■ n�i ��■■�� n��::�� N �� ■�� v��N�� u��U� ■��■��■��q�� WN� ■��■�� ....... �'.��......�uCi�:.:. _ � ..:■�_'.�: ...■... . ...... :::::::::_�.::::::::::::::::'::::�:.:. 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