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1866 Angell Rd ,. �y.-. ., t `�.1.' .i„1t .r."k. ,� •• --r>k S9S.:r,:��..+. ..s KY�k. .ate.;,,-... ,; yir ? L' DAVIE COUNTY HEALTH DEPARTMENT °: 160, 00 IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION , *NOTE:Issued in Compliance With Article I I of G.S.Chapter 130a tntary Sewage Systems r' PermiTL aer NamDate �� r _ J NO ( .7 . ..� Lggation r- Subdivision Name Lot No. Sec. or Block No. Lot Size House Mobile Home Business Speculation No. Bedrooms No. Baths No..in Family Garbage Disposal YES p NO 9pecificatiops;for System: Auto Dish Washer ' YES NO p �� Auto Wash Ma shine YES j NO 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. provem nts permit by -- 'Contact a representative of the Davie County Health Department for filial 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 J System Installed by t� h V Y; 4 Y bb Li a6 ' \ Certificate of Completion '�-' Date J t I '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. C W APPLICATION FOR SITE EVALUATIONIIMPROVEMENTS PERMIT__ Davie County Health Department f i 1E C E E ) Environmental Health Section Opp P. 0. Box 665 SEP 2 71993 Mocksville, NC 27028 C-\1� Ccc, e 1. Application/Permit FXquested By. XMailing Address r -a Home Phone h- cLc'—,�¢ rc_-121110 Business Phone /QyU 16� 2. Name on Permit if Different than Above 3. Application for. 0 General Evaluation optic Tank Installation Permit 4. System to Serve: 14-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 [ Washing Machine No.of Bathrooms ,-- ❑ Dishwasher Dwelling Dimensions ❑ Garbage Disposal 6. If business, industry, place of public assemb y, 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 5Z CLr� Sewage Disposal Contractor 9. Do yop anticipate additions/expansion of the facility this�ytem is intended to serve? ❑ Yes �"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 orthe intended use change. Effective October 1, 1989. Directions to Property: tZ LI-Q- 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 SIGNATURE CONSENT FOR SITE EVALUATION TO RE DONE QH ABOVE PROPERTY Fand ECK ONE: 1. I OWN the property. DESCRIBED PROPERTY DO NOT OWN the Property ked Box#2,the rest of this form MUST be completed by the owner or a person authorized by the owner: ve consent to the authorized representative-of the Davie Coun Health Depart!ent to enter upon above described cated in Davie County and owned by `-4 �� y...r- all testing procedures as necessary to determin said site's s itability for a group bsorption sewage treatment al system. DATE SIGNATURE DCHD(1/93) • f I.��E 1 r ��� a :,L . .i i. . _- 1 .. ... _ .._-. .- _. - - - ..._ 1 V � � . ., � .. ,. ,. .. I-- . , ., .. .. ,i i !1�: � � �9 .. .. ... I ' .. A ��: 1 ` _ � .. — _. . .�� . ... . , s i S ,;c �. li, ,. �� .( .. • .. . .. ' 11 .7 ,,7:.ry �. ,�. r ..tl. r-�r:;vn:,.:�_ :.u,,, r:.�R.., r wl:). 1 ,.. iDAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation NAME DATE EVALUATED ADDRESS S RV'-`- PROPERTY SIZE b > PROPOSED FACIILTY Rd LOCATION OF SITE Water Supply: On-Site Well Community Public Evaluation By:Ct.1— Auger Boring ��_ Pit Cut FACTORS 1 2 3 4 Landscape position > S Slope 9. ' 1 Su ' )5 HORIZON I DEPTH b Texture grOU2C C C �- Consistence F 7 Gx Structure C-I Z 2- MineralogX ; 1 1 HORIZON II DEPTH Texture groupL L Consistence Structure < Mineralogy HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS S SS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION S LONG-TERM ACCEPTANCE RATE ,L \A SITE CLASSIFICATION: .5 EVALUATED BY: LONG-TERM ACCEP ANCE RATE: OTHER(S) PRESENT: REMARKS: 3A - __�' '»\y 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 Mi neraloizy 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 CCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCC�CCCCC'•■CCCCCCCCCCCCCCNCC ■■■■■■■.....■.■■■■.■...■■■■■.■■■■.■■.■.■.■■■■■.■■■ E■■■■M■■E■■■■■ ■■...■■u■■■.■■■■■■.■■■■.■■■■.■■ ■■■.■■■■■ EM■■u■.■■.■.■■■■■ ■■■ ■■■■■■.■■■■.■■■■■■■■■H■.■■■■■■■■■■..■■■■■■■■.■N■■■■C■■■■■■■■■..■ CCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCC�CCCCCCCC�CCCCCCC ................................ ................................ ................................iC■E.■■■■E■E■■.C.................. ..............0■N■■■■.........■.....■..■..■■■ ■.EME■MME.EMM■MMEN ■.■ CCCCCCCCCCCCCCCCCCCCC'�CCCCCCC:.:CCCCCCC'�CCCCCCMEN MECC..CCCCCCC ...................................... ........................... ■■■■■■■■e■■■■■■■■■► ■■��■cauaaa■■■■Y■.■■Io.. 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