430 Hilton Rd (2) ,.,--..DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTE:Issued in Compliance With ArticlejJ of G.S.Chapter 130a
Sani�Sewage Systemsf�. , „� Permit Number
Name I;if Date — - i f N� U U
Location /`C' �� - / ✓"� ✓., r� /'/ Y, 1 -�. - ' _
Subdivision Name Lot No. Sec. or Block No.
Lot Size /r/7 L-_.— House _Mobile Home —_— Business —_ Industry
No. Bedrooms &Z-.No. Baths --/-- No. in Family _ Public Assembly Other
Garbage Disposal YES ❑ NO Specifications for System: 14 7A
Auto Dish Washer YES ❑ NO
r
Auto Wash Ma^hine YES ❑ NOj
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
ATTENTION: YOUR SEPTIC SYSTEM CONTRACTOR MUST SEE THIS PERMIT/LAYOUT BEFORE INSTALLING THIS
SYSTEM.
ay,
L^7.
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
Or
Certificate of Completion _ Date 441
_
'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.
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
NAME �� DATE EVALUATED
ADDRESS PROPERTY SIZE
PROPOSED FACIILTY LOCATION OF SITE .'l S�t�Y✓,�i
Water Supply: On-Site Well _ Community Publicy
Evaluation By: Auger Boring Pit Cut
FACTORS 1 2 3 4
Landscape position L ,L
Slope Z
HORIZON I DEPTH
Texture Sroup
Consistence
Structure
Mineralogy
HORIZON II DEPTH
Texture group e C
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: Akll
LONG-TERM ACCEPTANCE RATE: OTHER(S) PRESENT:
REMARKS: Oy✓ I_6'_
LEGEND
Landscape Position
R-Ridge S7Shoulder 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-Vl--ry 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
,3C--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
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-�� foo V APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department Environmental Health Section
P. O. Box 665
Mocksville, NC 27028
1. Application/Permit Requested By
Mailing Address '`y �`it 's Home Phone
AIC, 1700 to Business Phone
2. Name on Permit if Different than Above Sin
3. Application for. ❑General Evaluation 111"'S'eptic Tank Installation Permit
4. System to Serve: 9KHouse ❑ Mobile Home ❑ Place of Public Assembly
❑ Business ❑ Industry ❑'Other ❑ Unknown
5. If house, mobile home:Subdivision Section Lot#
B,'basement/Plumbing
No.of People ❑ Basement/No Plumbing
No. of Bedrooms 3 ❑ Washing Machine
No.of Bathrooms 2 ❑ Dishwasher
Dwelling Dimensions '�U X ❑ 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: Vkublic ❑ Private ❑ Community
8. Property Dimensions �S C Sewage Disposal Contractor
9. Do you anticipate additions/expansion of the facility t�is 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:
idkl
l,N
This is to certify that the information provided is orrect to the best of my knowledge,and I understand I am responsible for all charges
incurred from this application.
DATE SIGNATURE
CONSENT FOR B.LE EVALUATION IQ-ELE DONE ON ABOVE DESCRIBED PROPERTY
MUST CHECK ONE: lam. 1 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 said site's suitability for a ground absorption sewage treatment
ipposal system. Q _
S
ATE SIGNATURE
WHO(1193)' .