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150 Hickory Drive Lot 3 Section 3OD r 7rr DAVIE COUNTY HEALTH DEPARTMENT----� 4 IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION. *NOT-' Issued in Compliance With Article II of G.S. Chapter 130,a Sanitary Sewage System�`7/';/ z� �yr�Permit Number .t✓�7i�% ,,,, : Name � ��S'�,Y��C �f 7�!~ Date��-' _ N2 1 7 4 1i Location 4!!5 Subdivision �Name—�U'l�' ��'� %1 _ - Lot No. Sec. or Block No. _ Lot Size -- _ House —1--*" Mobile Home — Business -- Industry No. Bedrooms !i--Y--.No. Baths --�!-- No. in Family — Public Assembly Other Garbage Disposal YES ❑ NO 21" Specifications for System: Auto Dish Washer YES 4 NO Auto Wash Ma^hine YES NO ❑ �t�U� Type Water Supply --__-- ��.?X/ el *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. 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., 1:00-1:30 P.M. or 4:30-5:00 P.M. on day of completion. Telephone Number: 704-634-5985. Final Installation Diagram: System Installed by—�? r a,,x- EurW c%0� Certificate of Completion C_ Date Q ] "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 PE [Mmut ----------- Davie County Health Department Environmental Health Section 10 U n env A P. O. Box 665 `J env iw ��' Mocksville, NC 27028 G3AP 33) .; U, 1. Application/Permit Requested Byj-//w Mailing Address / 7X -Z-ay Z-57--1 Home Phone ;;Id / CYY- 3 Zai 9C4-%5-alzez AJ,G. Business Phone 2. Name on Permit if Different than Above1� 3. Application for: �,eneral Evaluation WepticTank Installation Permit 4. System to Serve: M -Douse ❑ Mobile Home ❑ Place of Public Assembly ❑ Business ❑ Industry ❑ Other ❑ Unknown 5. If house, mobile home: Subdivision u/Qlo.Q �7c-4cr s Section Lot # `c= ❑ Basement/Plumbin No. of People No. of Bedrooms -3 No. of Bathrooms Z:- -.:;o Dwelling Dimensions AG 0 - 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: 9-1:rublic ❑ Private 8. Property Dimensions /-30 X 236' Sewage Disposal Contractoi 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? If yes, what type? W ❑ Basement/No Plumbing Z; -Washing Machine [-Dishwasher ❑ Garbage Disposal ❑ Yes M-410- ❑ Community '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: u!'.v El'T /Ji4sT h. --1V-5'C//004 GvOO: C.4ES - e-- a TU c1Q �—c�/'ieJ L � �O LO T' d.til G EST. %/C/co/�y �/�/0 � - 3 SC This is to certify that the information provided is correct to the best of my knowledge, and I understand 1 am responsible for all charges incurred from this application. DATE SIGNATURE CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY MUST CHECK ONE: ❑ 1. 1 OWN the property. X 2. 1 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 County Health Department to enter upon above described property located in Davie County and owned by CAuOE« cuylE/L cymOil�y to conduct all testing procedures as necessary to determine said site's suitability for a ground absorption sewage treatment and disposal system. DATE SIGNATURE DCHD (1193) �. IZ3.91 • a a 1 40. 3� 0 `4� 0 U ry i a j jy 9 .o aap �I �tGK lsp. i,a i _ II�S � Is jTn ZP`. v nr � _ 3 -ip, rP ! �0�.43 31.73 143.21 �1 9s �5.93t 11.64:, 333 251 .95 150 1bo.65 - ry N ` ,in o r. DAVIE COUNTY HEALTH DEPARTMENT i Environmental Heilth Section Soil/Site Evaluation NAME DATE EVALUATED ADDRESS PROPERTY SIZE // PROPOSED FACIILTY � s? LOCATION OF SITE..f.Y�� rr�'eeIA. Water Supply: On -Site Well Community Public -✓ Evaluation By: Auger Boring t Pit Cut FACTORS 1 2 3 4 Landscape position ,L .4 Z /1-1 Slope -� HORIZON I DEPTH Texture group Consistence Structure MineralogX HORIZON II DEPTH Texture group Consistence Structure Mineralogy HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE , SITE CLASSIFICATION: -1f LONG-TERM ACCEPTANCE RATE: - C� REMARKS: DCHD(01-901 EVALUATED BY: Z'�/ OTHER(S) PRESENT: LEGEND Landscape Position R -Ridge S -Shoulder L -Linear slope FS -Foot 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-Silty <.lay loam, SIL -Silty loam CL -Clay loam SCL-Sandy clay loam SC -Sandy clay SIC -Silty clay C -Clay Moist VFR-Vcry 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 SC -Single grain M -Massive CR -Crumb GR -Granular ABK-Angular blocky SBK-Subangular blocky PL -Platy PR -Prismatic Mineralogy 1:1, 2:1, Mixed Notes Horizon 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 water' 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 ■��■��■�■ �r�■��■ ■��o■■��■��■��■��■��■��a■�■ ■��■�■■��■�■�■■ ■��r�■��■��o��■ ■��■��■��■■��■��■��■��■■ ■��■�� ■��■��■��■��■��■��■ ■��■��■��■��■��■�■��■��■�■ .....�...................................■.�.....■...■......■..... .......................................... ...................... .■...■...■...■...■...■...■...■...■.■.■...■■■■■..■■.■.■■■■■...■...■ ............................�... ................................ ................................�l........■......■...■............ ..................�........�.................■...■■■..■■.■...■.... .....■..................... .........................■.■.■........ .............................................. ..■..... .........■ ■■■■■■■■■■■■■■■..■■.■.■..■.■■■..■■..■■.■. ■■■■�■ ■ ■■■■�■■■■■■ ■■ .....■.......■...■...............■■....■.�....■.�■_■■■■■■■.■.■:�.■ .■...■....................■..............■...■...■...■...■...■■■■■ ...............................�...■...■...■...■...■..■■.■..■..■ ............................... .......................■...■.... ■■.■.■...........■.......................■.....■.■.■.■..■■...■...■ ■��■a��■��■��■ �� ■��■��■��■�■��_�� ■�� ■��u��t�� ■��■��■��s��■��_��■��■C��_■ ■��■��■■��■��■��■� ��■� �� iiiiiii�iiii�iiiiiiiiiii�ii��iiiii�iiiiii�iii=iiiiiiiiiiiiiiii�i�=i�i ■��■��N��q��[��n��/��_ ■��h��■��■��■G��■�� ■�� .........................................�........�.............1. .................................................. ............... ................................................o......... ....... ...........................�.............................■5....... ...........................�.....�................................ ■��■��■��iv��■■ ��■��v��■�� ■ .:�::::::::�:::::::�::::::C::::C:�:C:C�:::::C�:::::�::::�:: ��■��■��■��■��■��w��■��_�� n��■�� ■�■■�■��■��■■■�s=======�:a�:�:�� ■� ■��_��■��u�� ■��■��■��■��■��■�n��■��■ ■��■��■��■��'��■�� iiiiii�iiiiiii�iiiiii�iiiiiiii ' iiiiii�iiiiii�i=iii��iiiiii� ........................�..............■.�....■... �. ............■. :::::::::::::::::::::C:::::::::::::'�:::':::':_' :::::::C:::::::: ......................................�.►.�..■��. . ..■..�........ ...................................... .� ...�� ..... ........ ...........................:.:...:::::�..�� . �. .■C=::::::� ....................... ........� .... .... .. .. .�.. ■��I�� N�� r��■�u�� ■��■��\��■�� ve��■�� ...................................... �:i .......0 � ................................... ........ .o.... ��■�■��■��■��H��n�h� ��\��■� :::::'::::::::::��::::::::::::::::':::��:L�'.' ��:��C:: :'.:':::. ................................ _..... :�:::::::::::::: �:::::::::::�::::: .■_. ..�.............. �': .. ....■......... ■�� ■��H�� ■� ��■ :::::::��C:�::::'::_::::::C:::::.:::::..... ■..�........_.�.. .... .■ ........... . ..................................... . . ...■:C ... ...■..... ...............................�......'=.�.�C....■�.�...C..... .. ................................ ....... ...................C:... ■...........■...................�i....... ..■....■■............... ■��■��■■��N�� n��N��n�� ■��■��u/��■�� Nn�H��/��s��\■ ��H��■��\ U� �� ■�■��p��■��■ ��Nn �n��N�� .........................C........._............■................. .................... .............. .............................. ....................C...........�.....■.......................... ................................ ................................ .................................................................. ...................................... ........................... .................................................................. .................................................................. .................................................................. ■...........................................................■...■. ■��■ ■��N��■��■��■��■ ��/��\��U�� ■��/��■��/��■��■ ■��/��■�i�� Dame Count) Aeallli De ar&nenf and ..poke Nealt�i len •9eJ' 210 HOSPITAL STREET I P.O. BOX 665 MOCKSVILLE, N.C. 27028 PHONE: (704) 634.5985 August 17, 1994 Jim Moore 178 Ivy Lane Mocksville, NC 57028 Re: Site Evaluation Southwood Acres Hickory Drive Dear Mr. Moore: As requested, a representative from this office visited the aforementioned site on August 12, 1994. Based upon the information provided on the application for a site evaluation and after the evaluation was completed, the site was found to be provisionally Suitable for the installation of an on—site sewage disposal system. If you have any questions, please feel free to contact this office. RH/wd Enclosure Sincerely, Robert B. Hall, Jr., R.S. Environmental Health Section