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P7635 Houston Rd ..: a, .. i..iF-"Y F.41t.`.•ai_.i�W v'jt'.t-r:i ...X ,--vgry, _ /�- DAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION 'NOTE:Issued in Compliance With Article II of G.S.Chaptef 130a Sanitary Sewa e, ystems Permit Number Name�6 �L J ` " `YD/'r f'�-l�sX/ � Date � ��/ WO 7 6 3 5 Location � � //Jt�•l` �i c._ t� T11 �! ✓ i'l { 4el Subdivision Name Lot No. Sec. or Block No. Lot Size House Mobile Home — Business _— Industry No. Bedrooms J' No. Baths.—c;-2– - No. in Family— Public Assembly Other Garbage Disposal YES ❑ NO E�' Specifications for System- Auto stem:Auto Dish Washer YES NO ❑ /DO* / a / Gt Y i Auto Wash Ma^hme YES NO ❑ y Type Water Supply 'This permit Void if sewage system descr' eta d b 6w is not installed within 5 years from date of issue. This permit is subject to revocation if a pl s or the intended use change. 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 Ntuber:704-634-5985. Final Installation Diagram: Q Syste Installed by0 ee Y 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. 4 ;.:, APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PER Davie County Health Department R EC E U V Environmental Health Section P. 0. Box 665 JUN 2 1 1994 Mocksville, NC 27028 1 1. Application/Per st By � ©/� t� Mailing Address n� /�, ��- Home Phone-7 y�0T9 �i�I1h 4.'40, •c _ Idoh Business Phone 2. Name on Permit if Different than Above 3. Application for: ❑General Evaluation XSepticTankInstallation Permit 4. System to Serve: I� 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 /Y00 Sit �]� ❑ 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 ❑ PrivateCommunity 8. Property Dimensions l] Q C kf4 c Sewage Disposal Contractor 4r 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes f,�' 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: 601 ;9 0,J�. /C( D62 �-j '709' rQ/r�,L /��e7' aU ��°�-,per y ��✓-�- -rv�.¢ss This is to certify that the information provided is correct t he best of m knowledge, and I understand I am responsible for all charges incurred f om this application. DATE SIGNATURE CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY F CK ONE: ❑ 1. 1 OWN the property. (a 2. 1 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: e consent to the authorized representative of the Davie County�alth epartment to enter upon above described ated in Davie County and owned byall testing procedures as necessary to dete ine said site's suit bility for a ground absorption sewage treatment l system. DATE SIGN RE DCHD'(1193) ti ( • "-' DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation NAME ` C' DATE EVALUATED ADDRESS PROPERTY SIZE PROPOSED FACIILTY ��b�0"LIfC LOCATION OF SITEC.Lf' � Water Supply: On-Site Well Community Public Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3 4 Landscape position .C� Sloe Z -^ HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH Texture group Consistence -777 47 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 !:lay 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 ■■■■/■■■.■■.■.■■■■////■■■■.■■■■■■■■■■■■/...■■■....■.■...■../MEMO■■ ■..■■.■■■■.■■■■.■..■.■.■.■■.■.■■■..■OOM..■■M■E■MMM■M■■ME.EM.ENIN■■ ■.■■..■uM.M■■M■.■■■.■.M■.■..■■■�.■■■■■■■■�■..■....■■■■..■■.0 ■■■ ■■■■■■■■.■.■.■..■...Oi,�M■NM.NOM■OO.O■■OMOJE.MO.N■MM.N■.MN■.■■MM■.■■ 'iiiiiiiiiiiiiiiiiiiiiiiiiiiiiii�.�iiiiiiiiii'iii■iiii�■iiiiiiiii'iiii ■.■.■....■.■■■.■..■..■.■> ■■...■■.....■....■>•■....■.■.■. 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