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240 Big Oak Ln (2) .r.. _ — - - ae•-.._-^'N"- ,.. -_t' .,r "TM^;^:±+.,lv"•+wa.�•t'',^'v"""'•".'^tl..-C`_....rw�sw,+ii. —"„a.�-l„"r�a I� __ -_ ISM, DAVI.E COUNTY HEALTH DEPARTMENT;. P.. IMPROVEMENT$ .PERMIT AND CERTIFICATE .OF COMPLETION 'NOT :Issued in Compliance With Article II of G:S:+Chapter 130a °. Sanitary Sewage Systems I Permit Number Name �_ — 0- 1 .8 Date N ] k Subdivision Name lil --- Lot No. Sec:or'-Block No. Lot .Size _} _ House _ Mo6ile Home _ _ Business __ Industry Nto. Bedrooms No. Baths _ _ NI in'Family ✓ — . Public Assembly Other Garbage Disposal ._ YES p NO' j` Specifications for System; Auto-Dish Washer YES p NO ❑ "�, Auto Wash Ma^hine YES [] ,NO ❑ Type.Water Supply , - This.permit Void if sewa* e system described bellow ris not installed 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 INSTAWNG THIS SYSTEM. t n ' 1 I n . ' ^,tar_xfu'. i*~;c•Rx,,,...„,;� �d K;,. x him"' Improvements perm�t`by ' .a r I '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.' • ill. .. .. , • , Final Installation Diagram` . System.Installed,by /J ee )Ce i ` „ ^ it - »../1 ,.� --�.✓.q�t� � C 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. i-r APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PE d j �__• Davie County Health Department ' Environmental Health Section 3 P. O. Box 665 .rA=W 2 Mocksville, NC 27028 W ONM SAL HEALTH 1. Application/Permit Requested By �� �� OAK UNTY Mailing Address ©k 1-3 -7 Home Phone 9JP 7,1 �eCi&zZ412f Business Phone 991?-.3-6h- 9 40 2. Name on Permit if Different than Above 3. Application for: — El General Evaluation �ptic Tank Installation Permit 4. System to Serve: t�lf ouse ❑ Mobile Home ❑ Place of Public Assembly ❑ Business ❑ Industry ❑ Other ❑ Unknown 5. If house, mobile home: Subdivision Section Lot # 2-Basement/Plumbing No. of People Ll ❑ Basement/No Plumbing No. of Bedrooms 3 R Washing Machine No. of Bathrooms o2 E�Tishwasher Dwelling Dimensions___ 2, X SQ l"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 private ❑ Community 8. Property Dimensions :Z Sewage Disposal Contractor 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes ZrIN—o 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: 46 Avvice— l�GQ� ✓ �Gc°`/sem �G�li!?1��L Old rj'd["s iN �opSL �f E'DrPa l - 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. ��5-- 9s— DATE SIGNATURE CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY MUST CHECK ONE: E/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. DATE SIGNATURE DCHD(1193) �= DAVIE COUNTY HEALTH DEPARTMENT J •� Environmental Health Section nl / Soil/Site Evaluation NAME DATE Yl/� DATE EVALUATED ADDRESS PROPERTY SIZE PROPOSED FACIILTY a LOCATION OF SITE Water Supply: On-Site Well _ Community Public Evaluation By: Auger Boring / Pit Cut FACTORS 1 2 3 4 Landscape 2osition ,(r Slope % 4 HORIZON I DEPTH <5�21-+ " Texture group Consistence Structure Mineralogy HORIZON II DEPTH s 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: Rr EVALUATED BY: LANG-TERM ACCEPTANCE RATE: il OTHER(S) PRESENT: REMARKS: 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 CONSISTENCE Moist VFR-V+--.-y friable FR-Friable FI-Finn 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 .3C--Single grain M-Massive CR-Crumb GR-Granular ABK-Angular blocky SBK-Subangular blocky PL-Platy PR-Prismatic Mineralocty 1:1, 2:1, Mixed Notes Ilorizon 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 DCHD(01-901 ■..■.■...■..■■■■■e.■.■M■■■■■■.■■■.■■.■■■■■■■■■■■■�........ 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