2576 Hwy 601S+� .>-:. t ,i.,.. P p +, Kg4s ti'e w.GQ r 'r -: ..,t 3' . - }.:+J ,. c*A .:`r.. ... ,. ..; � �,�,�,v!..e .r t•-r.e� : L .tl - a ts.r .. '-a;t.
DAVIE COUNTY HEALTH DEPARTMENT
f y IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTE: Issued in Compliance With Article II of G.S. Chapter 130a
Sanitary 0 S's
tems 1
Name — Date .
Location
Permit�yNer
N°
Subdivision dame Lot No. Sec. or Block No.
Lot Size H e Mobile Home Business S eculation
No. Bedrooms
Garbage Disposal
Auto Dish Washer
Auto Wash Ma^hine
Type Water Supply
_.No. Baths No. in Family _
YES ❑ NO Sp cifications- for System: .-
YES ❑ NO 1
YESrG NO
*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
Ha_,QQ-- W e,
*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:
4� 2 -
System Installed by —�JCA"S -os-te
Certificate of Completion Date
'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.
Ck APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department
G� Environmental Health Section
P. O. Box 665
J! Mocksville, NC 27028
1. Application/Permit Requested By. -�ym
Mailing Address �I a max �%� - n�i/��i )C�, AlY, a!z vo
Home Phone Business Phone
2. Name on Permit if Different than Above
3. Application/Permit for:
4. System to Serve: ouse
[Business ❑ Industry
5. If house, mobile home: Subdivision
❑ General Evaluation
❑ Mobile Home
❑ Other
No. of People �� � A �1 G Y s—
No. of Bedrooms
No. of Bathrooms
Dwelling Dimensions
6. If business, industry, place of public assembly, other: Specify type
No. of People Served ?
No. of Commodes
No. of Lavatories
No. of Showers O
No. of Sinks
No. of Urinals
No. of Water Coolers
Water Usage Figures
7. Type of water supply: R(Public ❑ Private
8. Property Dimensions 2,90 X I QQ Sewage Disposal Contractor
21"Septic Tank Installation
❑ Place of Public Assembly
❑ Unknown
Section Lot #
i
9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes
If yes, what type?
❑ Basement/Plumbing
❑ BasemenVNo Plumbing
❑ Washing Machine
❑ Dishwasher
❑ Garbage Disposal
❑ . Community
ff"No
*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:
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.
3 93 mw
DATE SIGNATURE
CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY
MUST CHECK ONE: [9'1. I OWN the property. ❑ 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
to conduct all testing procedures as necessary to determine said site's suitability for a ground absorption sewage treatment
and disposal system.
�-
°3 �/' li-1Z,
DATE SIGNATURE
DCHD (12-90)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
NAMEDATE EVALUATED
ADDRESS PROPERTY SIZE
PROPOSED FACIILTY LOCATION OF SITE 42DI-r- ,�t%
Water Supply: On -Site Well Community Public z,--
Evaluation
,Evaluation By: Auger Boring t/ Pit Cut
FACTORS 1 2
3
4
Landscape position ,L
Sloe % — -
—
HORIZON I DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH
Texture group'
Consistence
Structure r'le
Mineralogy
HORIZON III DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
S
LONG-TERM ACCEPTANCE RATE1 22
7-77577
7
SITE CLASSIFICATION: elc
LONG-TERM ACCEPTANCE RATE:
REMARKS:
DCHD(01-901
EVALUATED BY: 1411
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 clay loam, SIL -Silty loam CL -Clay loam SCL-Sandy clay loam
SC -Sandy clay SIC -Silty clay C -Clay
Moist
VFR-Very 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
Mi neraloay
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 watef 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
y Davie County Neat i De artment
and glome NealtFr yency
210 HOSPITAL STREET I P.O. BOX 665
MOCKSVILLE. N.C. 27028
PHONE: (704) 634.5985
March 11, 1993
t
Mark S. Grubb
Rt., 21 Box 372—A
Advance, NC 27006
Re: Site Evaluation/Business
Corner of Hwys. 601S. G 8015.
Dear Mr. Grubb:
As requested, a representative from this office visited the aforementioned
site on March 8, 1993. The site 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
Enclosure