The URL can be used to link to this page

188 Cambridge Ln (2) s DAVIE COUNTY HEALTH DEPARTMENT y d IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION_ r 'NOTE:Issued in Compliance With Article II of G.S.Chapter 130a Sanitary Sewage Systems Permit Number �- � �, _ Tom, �- 800 Name - — �- _--Date Location Subdivision Name Lot No. Sec. or Block No. Lot Size `'` = House — Mobile.Home — Business —_ Industry No. Bedrooms —�.No. Baths _-1_ No. in Family — Public Assembly Other Garbage Disposal YES ❑ NO Qs Specifications for System Auto Dish Washer YES ❑ NO p.- / b c, ci r r,: .,,, { - V) _ Auto Wash Ma^hine YES Lg NO ❑ sa t l Type Water Supply *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 ATTENTION: YOUR SEPTIC SYSTEM CONTRACTOR M T SEE THIS PERMIT/LAYOUT BEFORE INSTALLING+THIS SYSTEM. .. ion 7-3- 91�- ^^� V-O dui t�a P 4 « p f�4- 0 Use Impr vements 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 Diagra System Installed by y� 07 S Iyo� N U� Certificate of Completion — _ _— Date 'The signing of thi II 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 as a guarantee that the system will function satisfactorily for any given period of time. .. ERR APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PER Davie County Health Department .. 9 in Environmental Health Section . P. O. Box 665 Mocksville, NC 27028ENVIRONMENTAL HEALTH DAVIE COUNTY LAJ1. Application/Permit Requested Byt s 5 a �k�'� Mailing Address �� "�`- Home Phone Business Phone 2. Name on Permit if Different than Above -` 3. Application for: eneral Evaluation %'septic Tank I stallation Permit 4. System to Serve: ❑ House t2-M&ile Home ❑ Place of Public Assembly ❑ Business ❑ Industry ❑ Other ❑ Unknown 5. If house, mobile home: Subdivision Section Lot # ❑ Basement/Plumbing No. of People I ❑ Basement/No Plumbing No. of Bedrooms EB-Washing Machine No. of Bathrooms r ❑ Dishwasher Dwelling Dimensions ❑ 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 e 6 a Sewage Disposal Contractor 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes PrNo 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: -�—p C CL rnbr iLG. C Y-Irc,'— k (��ere larcL � 5 0�• 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 fromrrth's a plication. DATE SIGNATURE CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY Q MUST CHECK ONE: f. 1 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 syst M. ATE SIGNATURE DCHD(1193) s DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation NAME LDATE EVALUATED ADDRESS s A ww::: PROPERTY SIZE PROPOSED FACIILTY M„ ` LOCATION OF SITE p. 1..u• Water Supply: On-Site Well _ Community Public Evaluation ByC i��AugerBoring Pit Cut FACTORS 1 2 3 4 Landscape position s 0 --S Sloe % v b'" y_)SQ 91- 1161, HORIZON I DEPTH " " AD N Texturegroup __ 4- Consistence Structure \'Z Mineralogy '. ( ;1 HORIZON II DEPTH " 4Z" ,�� 't-z" Texture group Consistence F71 1 (Z-71 Structure 1C 1 N:4- Mineralogy HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON J SAPROLITE — CLASSIFICATION 9. 5 LONG-TERM ACCEPTANCE RATE I " 'k SITE CLASSIFICATION: .S EVALUATED BY: LONG-TERM ACCEPTANCE RATE: _OTHER(S) PRESENT: REMARKS: . % - EGEND 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-Vf--.-y friable FR-Friable FI-Film 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 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 DCHD(01-901 ■...■..............■■■■..■■■■■■■■■..........■.eN■ .■■.■■.■ ENOES.■ ■■■■■■...... ...■■...■.............N...NNse..eee�i■■e■■■O■■.■■■■■■ .......................................... ........ ............. ■..■■■■■.■.■■■■■...■.■..■....■■■....N.....■eeee■e■e= ■■■■e■■■■e■■■ ........................... ................... .... ............. SON 0 ................■........................ ... . . ... ......MINN ONE mommomms No ............................................■.... ■■e■e■■e■■■■■..■ ..■............................ ■O■.■■■...............■■.■O■■■■■ ■..■...■.■■■■■....■■■■..■■..■..ii::�■1Sr!!...SN■..�.�.■■■S.c■■■.ecce■ MEN .........................■.................■...■■ ■■■ .EN�■■■■.■l ..................•.............................. MEN. NE■c■■ ..........■...................................■._ �E::m"NEEMEN ■.N..■■...■■.■cS■■c■c■■N.Sc■■■■ .S./HSec■e■ 010 ME Nc■■E■■ ■■.■■■■■■...■.■■■■■■■■....■..■... ■ MESONIN ■ MEM MN 0 loom omoommo ■...■■S.■e.■■■..■■.....■...i��■.■ ■ ■. .■ N.. ■■■■■■■■■l ESEM"MMEME MEMEM"■cl'ssm�ce.. ccc■c cmmoo\moi ■.;..r '' NOON ■ ■ ■ ■■e.■ee■■ee.e..eeeeee■N■e=■■.■■e■e.■e e�.e.e■■N.. ■.....a■....■■■■....■...■.■..��.��.� /.v ■ ME MME ■.......■..N.N.....■........►�. ��i�u� No e.■N■.�.. ■EE■■■■E■■NE■EE■■■OEHE■■.E■■E■E . HE■N.i■.�.■■■ OEM MEN EE■E■.. .■cee..He.■m.N...N■ Se .Ne .E■NON MOEN ME ME MENOM ■NOON■■/eecc■ccc■Hc■■i=iccc.ceH■ N �•• �. .c ■■ H■■■■■ MONSOON N■■IU■■■.ENEE■E.■E■■N■N■I ■■ ■ H■Re ■....e..N.e....■.■...■■...N..■.�... NN■■■■■JIM E ■■EMEMEN MEMS MINuiii MENEEMEMENOMMEN ■ ■ ■ eeiii=i■UMMEi■ ■■■■■■ ■■ ■■■�■ ...■■E■N■■■■■■ No MEN MEN ....0■■■■■■■■■■■ ■ONES ■■m■■■■...�.........■.�. ■. .■■.■.. N■N...N■■■■H.■■ .N■■■.■■■N■■...N.■...■..■■■.■■■ N■.S...O■......■■■■■■■■■■■.■.■■ ■■■■■■■■■■UH■■■■E■■■■■■O■■■■H■■.■■■■ ...■■■■■.....■.■■N■■■■■■■ MOE�INEONEENENMEMEMMENE■NOM �MM MMEEMEEMEMMENE VM 0 ■■SONO N■■■N■■■■■■■■■.■■..■■■NN■■.N. ■ ■■■■N■■■■N■.■■■■■■■■■■..■