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124 Green Farm Rd V/x e DAME C®UNTIY HEALTH DEPARTMENT " . IMPROVEMENTS PERMIT AND CERTIFICATE ®P COMPLETION *.NOT Issued in Compliance With Article 11 of G.S.Chapter 130a Sanitary Sewage Systems Permit Number Nam ' I �1eIr f Name � _ Date. r Z---J1/-:'/ / N® 741 .5 Location 1J` zero", ll'. r�s�e. 1 Af ,/G✓./ �'sYG^; r,-c'` :f. /%;-: . Subdivision Name Lot No. Sec. or Block No. Lot Size J�/ House 1-1'� Mobile Home Business -- Industry No. Bedrooms ' No. Baths ` �� No. in Family -� — Public Assembly Other Garbage Disposal YES ❑ NO ❑ Specifications for System: Auto Dish Washer "'YES ❑ NO ❑ ' Auto Wash Ma thine YES ❑ NO ❑ �'" Type Water Supply *This permit Void if sewage system described below is not installed within 5 years f`rom+date of issue. This permit is subject to revocation if site plans or the intended use change. i 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 X ^Q Z ,l 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. , t, APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT Davie County Health Department FE Environmental Health Section P. O. Box 665 5 1994 Mocksville, NC 27028 1. Application/Permit Requested By -Te r r J L flly r S Mailing Address 47-1 401 S-K6 Home Phone V9- kQ a�- d OLIdI l e- mac- 2 70 0 Business Phone �3 Z-/_ OR-7 2. Name on Permit if Different than Above 3. Application for: ❑General Evaluation Septic Tank Installation Permit 4. System to Serve: House ❑ 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 3 ❑ Washing Machine No. of Bathrooms 9. ❑ Dishwasher Dwelling Dimensions IL 0 s Qy i re- Fo o f ❑ 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 ) '4cre Sewage Disposal Contractor 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes ,,�No 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: G 0 / /1/, ro G r•e e n f r r? kD rj a ;to Tv Pc�s 4urc To CIZ j S ours 7'hf✓C- 6 S%e,4 _S P,7- v P fro r? Grr•en ,Q ID 7-0 5?eul! 1 S GL,rS 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. DATE 'PURE CONSENT FOR SITE EVALUATION IQ BE DONE ON ABOVE DESCRIBED PROPERTY MUS/T-,CHECK ONE: u-i I OWN the property. ❑ 2. 1 DO NOT OWN the property. If you chfcked 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 representativq of the Davie County Health Department to enter upon above described property located in Davie County and owed by to(conduct all testing procedures as ne essary to determine said site's suitability for a ground absorption sewage treatment and disposal system. a DATE SIGNATURE DCHD(1/93) - L , ti DAVIE COUNTY HEALTH DEPARTMENT • Environmental Health Section Soil/Site Evaluation NAME DATE EVALUATED Z�7�4;� ADDRESS PROPERTY SIZE PROPOSED FACIILTY LOCATION OF SITE Water Supply: On-Site Well Community Public Evaluation By: AugerBoringPit Cut FACTORS 1 2 3 4 Landscape position %L Sloe Z �- HORIZON I DEPTH Texture group Consistence Structure Mineralogy 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 RATEI V I / SITE CLASSIFICATION: EVALUATED BY: 'A14 LONG-TERM ACCEPTANCE RATE: C 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 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. 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