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1594 Angell Rd 1. DAVIE COUNTY HEALTH DEPARTMENT g �+ IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION *NOTE Issued in Compliance With Article 11 of G.S.Chapter 130a r Sanitary Sewage Systems Permit Number Name-& '.J/e "-bate N0 7768 Location CJ/7 �1�'/' � '� �/ J�r�/✓ �/�✓[r_ I"�,':r�//a/ C�dU 1//Jr �'�7' � .e�`�� � "Subdivision Name Lot No. Sec. or Block No. Lot Size C House Mobile Home _k Business _— Industry No. Bedrooms �.No. Baths _-/—_ No. in Family .2Public Assembly Other Garbage Disposal YES ❑ NO p< Specifications for System: " Auto Dish Washer YES NO ❑ z Auto Wash Ma shine YES NO ❑ ��% J _� Type Water Supply — e&4ZZ *This permit Void if sewage system described below is not installed within rs from date of issue. j This permit is subject to revocation if site plans or the intended use change. wi Improvements permit byZ1 *Contact a representative of the Davie County Health Department for final inspection of this system a :30-9:30 A.M., 1:00-1:30 P.M.or 4:30-5:00 P.M.on day of completion.Telephone-Number:794-634-5985. Final Installation Diagram: em-ki ed b \ 9 fur�v�95't by 68 uhJJ FGFN L 9 `P SD`b 0 5 cc) i Tk ti r { Certificate of Completion `- � � 9., Date ") - 3 'The signing of thjs 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. APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT Davie County Health Department Fp Environmental Health Section U W/P. O. Box 665Mocksville, NC 27028 71994 1. Application/Permit Requested By. Ben 1 Q tv%,", I—Ta c o d Mailing Address 15511 O.:t4 �� Home Phone ���e� 91�R-013 aF JMc)C-kSJ•<<l e. A)C_ Q0609 Business Phone(06y) b3`t-6a�/��KfBs�y� 2. Name on Permit if Different than Above �ASk-�r919C4� 3. Application for: ❑General Evaluation &eptic Tank Installation Permit 4. System to Serve: ❑ House Ct ,Wobile 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 a "ashing Machine No. of Bathrooms p 2"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 21Private ❑ Community 8. Property Dimensions Sewage Disposal Contractor 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes , , 12No 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: 4k /I Woad i c jGya- 7 ye�• Neic J/r.-J o4-s G., c,ccrss V here 4S 01111 otic pn.( I resrPhi c �c✓�y . 601 N04'- -10 A'Jell t1J, 4('1"- r�l.+ So I I ow a pfrox, l h d, 4D 61-eeh �ti�f Gn o ;I �,or,,, I�uc 4 L e f� 6,(c o�, ��� �� t,� l�ell�� WA bras" 5-AG.4rjJ PI(-,�)Se Cj,-// a-ger Np•�-- 4,e &�J 646re I/oc,, heed 4b co rn e 01J. 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 01IGNATURE CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY Fanddisposal ECK ONE: ❑ 1. 1 OWN the property. a-1 I 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 D ye County Health Department to enter upon above described cated in Davie County and owned by I ad, ici h(P" �M� all testing procedures as necessary to�etermine said site's uitability for a ground absorption sewage treatment al system. DATE SIGNATURE DCHD(1193) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation NAME _7, i �G DATE EVALUATED ADDRESS PROPERTY SIZE PROPOSED FACIILTY LOCATION OF SITE Water Supply: On-Site Well, Community Public Evaluation By: Auger Boring _L1__ Pit Cut FACTORS 1 2 3 4 Landscape position Sloe Z � HORIZON I DEPTH Texture groupL L G�C 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 RATE / SITE CLASSIFICATION: EVALUATED BY: LONG-TERM ACCEPTANCE RATE: % 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 Mineralo¢y 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 ■..■......■..........■...M....■■■■■■■■■■■■..■...■■...........■■NEM ■■■■.■■...■■■■■■■■■■■■■.■■■.■■...■■■■MOON■M■■..■..■■■■■■■■■■O■■■.■ ........................... ...................................... .■■■■■■N.■■.■.■........■....■..�.■....■■■�■■■■■.■■■■■■■■■... ■E■ .................................................. ............... ■■■..■■....■■■■.■■■■■■■■■■■■ ■i. :i■■..■■■■t.N.MN■■■■■..■■■■.■■■ ■■■.■■■■■■■■■■■■■■■■■■...Mir■■■■■■.■■■■■Ori■.■■■■■■..■■�■■■■ ■■■■■■■ MMMMrAmmMMMMMMmMmMMMMu ■■■■.■■■.■..■■....■..■E■■■.....■■..............�.■..■■■.■�■■■■■■■■■ ■■■■■.■■■.■■■■■..■■■■■■■■■■■■.■■■%■... .■�■■■■■.� ■■■■■■■■■■■■■ ■■.■■....■....N■■■■.■..A■■■■■■.■■■.■■ .�■■. 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