255 Riverstone Trail _ e
A ' DAVIE COUNTY HEALTH DEPARTMENT
: IMPROVEMENTS_:PERMIT AND ,CERTIFICATE OF CaOMPLETION'
"'NOTE:Issued in Compliance With Article ll of G.S.,Chapter-130a `
S"anitary.Sewage Systems PerMit Nu
imber
Name`�f. ? :a^ v� is�,� . rr �`G s_`ic�. Date d%r." 5 N2 81 12
Location
i - ,e, r it 6 �' eJ�`, /'t
IV c l �� 1i�L c.f AJ:
Subdivision Name`,'-" Lot No. Sec:'or Block No:
Lot Size _ ✓ -"House Mobile Home ' Business--�_ Industry
No. Bedrooms,` No'" _* ` :No. in Family, Publi5,Assembly Other
Garbage Disposal YES p NO ❑' Specifications for System: t
Auto Dish Washer YES p NO p
Auto Wash Ma hine YES p NO []
Type Water•Supply..'___
'This permit Void if sewage system.descr bed below is not installed with'ih 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 INSTAWNGrTHIS '
SYSTEM, ,
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=�s�s;116 6 '
Final.tnstallation Diagram System Installed,by _
Certificate of Completion �Y2 _— 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.
..•
n
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT .
Davie County Health Department
Environmental Health SectionEf�'lfls o'ef:.'.%f1Tll.HEW11
P. O. Box 665 1 1SII GQ �1Ty
Mocksville, NC 27028
1. Application/Permit Requested By �/� Lcv /'!�`c.b�[^f�� (,AL �l
Mailing Address /`% G i6oK c��G Home Phone 7&r- /4/frt cifp'2f�
/'V-C A 7 Ud 6 Business Phone ?7 7 -/l 2 2-
2.
2. Name on Permit if Different than Above
3. Application for: ❑General Evaluation Er-S-eptic Tank Installation Permit
4. System to Serve: EKouse ❑ Mobile Home ❑ Place of Public Assembly
❑ Business ❑ Industry ❑ Other ❑ Unknown
5. If house, mobile home: Subdivision Section Lot #
❑ Basement/Plumbing
No. of People ❑�`Basement/No Plumbing
No. of Bedrooms 2'washing Machine
No. of Bathrooms -z �L }dishwasher
Dwelling Dimensions c3 5 X 6 2 ❑ 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 2-15rivate ❑ Community
8. Property Dimensions 6,0 'IuC c Sewage Disposal Contractor
9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes 9-<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: �{w� !rl Eifrf � /
POEM 4 F+-d TG wN — if�yyP/lw w /� i21. !cam 6 <+i.N i/ ��1
�'� (j;/ac"
Gt' �C�/N' j `Lc/v LJ�I�ITC C.�NLoC �cc�
Q N a J i J t O T' X 4 K C .
aish
This is to certify that the information provided is correct to the st of my knowledge, and I understand I 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. 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 aid si suitability for a ground absorption sewage treatment
and disposal system.
, )—
TE SIGNATURE
DCHD(1/93)
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS E1 �---
d Davie County Health Department ®
Environmental Health Section
l) JUN 19
�
yyG� P. 0. Box 665 1 9
Mockaville, NC 27028
1 . Application/Permit Requested By � 4dei ZDIc l�[JJ4l�
Mailing Address 10 .V ,�tr��,-ioo c� J/L L /U C 2-0000
Home Phone 99,P- 12--:/>ey Business Phone y? 2-1
2. Name on Permit if Different than Above
3. Property Owner if Different than Above 4y 44 EY/I_r
4. Application/Permit For: 9,"General Evaluation 0 S/Tank Installation
5. System to Serve: +House J Mobile Home 0 Business
0 Industry u Other 0 Unknown
6. If house, mobile home: Subdivision Sec. Lotus
No. of People .11 Dwelling Dimensions Afoa fc FA
No. of Bedrooms y ] Basement/Plumbing
No. of Bathrooms //z ^ Basement/No Plumbing
Washing Machine Dishwasher 0 Garbage Daspusa.i
7. If business, industry, 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
8. Type of water supply: Q Public 8--lprivate 0 Community
9. Property Dimensions ,3s-,4cA&
10. Sewage Disposal Contractor
11 . Do you anticipate additions/expansions of the facility this system is
intended to serve? 0 Yes B-INo
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.
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 applica on.
r"LIZI-11 (��, ze
ate Signature
Directions to Property :
V/J[-J:NNZ ,4J c, � A Y T/ T 0,
7a-
J,
/.1 /� /�'CI I'��+ Q K[C l•JN
/' It /1A t G'/ J 1 Jld J�/J CC/CA— �G Cs C,C../ le CA; �OGrw J
01411 CJOltt
DCHD (10-89)
DAVIE COUNTY HEALTH DEPARTMENT
~ Environmental Health Section
Soil/Site Evaluation 7
NAME Al�q& DATE EVALUATED
ADDRESS PROPERTY SIZE
JdCS-/ LOCATION OF SITE �/E�1,�
PROPOSED FACIILTY T
Water Supply: On-Site Well f Community Public 1
Evaluation By: Auger Boring 1/ Pit Cut
FACTORS 1 2 3 4
Landscape position -� L
Sloe % — —
HORIZON I DEPTH
Texture groupL
Consistence
Structure
Mineralogy
HORIZON II DEPTH 4-
Texture
Texture rou
Consistence
Structure
MineralogyJ i,-
HORIZON III DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION j
LONG-TERM ACCEPTANCE RATE
SITE CLASSIFICATION: — EVALUATED BY: /41
LONG-TERM ACCEPTANfgE RATE: & OTHER(S) PRESENT:
REMARKS: ;,_ee zdZ08-0Z,
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
CONSISTENCE
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
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
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F ,
Davie County , ealtfi 7ye
artment
and .dome Nealtlincy
210 HOSPITAL STREET I P.O. BOX 665
MOCKSVILLE.N.C. 27028
PHONE:(704)634-5985
July 3, 1991
Mr. Charles Michael Wall
104 Creekwood Drive
Advance, HC 27006
Re: Site Evaluation
Glen Allen Road
Dear Mr. Wall:
As. requested, a representative from this office visited the aforementioned
site on July 1, 1991. 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