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145 Hendrix Ln { r - DAVIE COUNTY HEALTH DEPARTMENT - IMPROVEMENTS PERMIT AND .CERTIFICATE OF COMPLETION *NOTE:'Issued in Compliance With Article II of G.S.Chapter 130a Sanitary Sewage Systems Pet Number Name ar r `r /.�.r�7^ ,�S"x �%: /��A_tJk Date 6 6 8 7 r Location r';/�,� %=" .��x' -i Subdivision Name Lot No. Sec. or Block No. Lot Size /✓f1t.. House Mobile Home __ _ Business Speculation No, Bedrooms *-J? No. Baths 6� No. in Family -� Garbage Disposal YES ❑ NO p- Specifications for System: Auto Dish,Washer YES © NO ❑ '� Auto Wash Ma shine YES p NO ❑ f Type Water Supply *This permit Void if sewage system described below is note stalled within 5 years from date of issue. This permit is subject to revocation if site plans or they ntendod use change. i Imp vements permit by — *Contact a representative of the Davie County Health Depar men for final inspection of this system between 8:30- 9:30 A.M. or 1:00-1:30 P.M. on day of completion. Teleph,ne umber 704-634-5985. Final Installation Diagram: Sys em Installed by r 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. APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT Davie County Health Department ' Environmental Health Section u if iL P. O. Box 665 �qq, Mocksville, NC 27028 FF 1 1. Application/Permit Requested By STA M E 5 K. P E N D R 1 C -� Mailing Address 5865 ToMAhfAtvK DR►VE,. WcNsront -SALEM, nl.C . 2710(D Home Phone Q l Q-9 Zq--I 0 a R Business Phone R l R -705 -2 62$ P? 2. Name on Permit if Different than Above 3. Application/Permit for: E!rGeneral Evaluation ESeptic Tank Installation 4. System to Serve: C/House ❑ Mobile Home ❑ Place of Public Assembly ❑ Business ❑ Industry ❑ Other ❑ Unknown 5. If house, mobile home: Subdivision Section Lot # R Basement/Plumbing No. of People 5 ❑ Basement/No Plumbing No. of Bedrooms 3 C9�`Washing Machine No. of Bathroomsp�Dishwasher Dwelling Dimensions 3 Z x 4 ❑ 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 VPrivate ❑ Community 8. Property Dimensions Sewage Disposal Contractor Do m N l E LAKE Y 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes B/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: (� p HW Y (0 4 EAST To 8 o l ) TURN LEFT O N-ry k VVY 901 TOWARD ADVAUCE') GO 19PPROX. I 2 MILES To FULTON RDI TOPW L r--r DluTo FUt.T" Ko AND C-1 o To TOP OF HILL . TA lcF PRIvAt-67' PIRT pp oN RIgHT) qo To PRIVEWAY $ESIDE OLD W14cTE BLOCK I..IpveE � IAlTENpEp �of1SE• 1317' E LS JUST Beromo DN LEFT IN LA R q E Q R A55 Ff E LD. 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. 2- 22- q2 DATE SIGNATURE CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY Fandd ECK ONE: [1�1. I OWN the property. ❑ 2. 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 Davie County Health Department to enter upon above described cated in Davie County and owned by all testing procedures as necessary to determine said site's suitability for a ground absorption sewage treatment al system. DATE SIGNATURE DCHD(12-90) r" it DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation NAME /t/�111/r'.t DATE EVALUATED 3'gG2 ADDRESS PROPERTY SIZE � lel o PROPOSED FACIILTY LOCATION OF SITE <A� Xel Water Supply: On-Site Well Community Public Evaluation By: Auger Boring ✓ Pit Cut FACTORS F-s"k— 2 3 4 Landscape position Slo e ZHORIZON I DEPTHTexture rou G -5-1— J-2— Consistence `GConsistence Structure MineralogX HORIZON II DEPTH F .yfr r" 4- Texture group Consistence Structure Mineralogy f. 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 i C SITE CLASSIFICATION: _, EVALUATED BY: 7s _elfl174 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 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 ■■■■■■■■■■■■■■■■■■■■.■■■e■■■■■■■■■■■■■■■■■■■...■■■.e■■.ee■ ■e,ms,,,�■■ ■■■■■■■■■■■■.■■■■■■■■■■.■.■■■■■■■■■■■■■.■■■■■■■■■■■■■■■■■■■■Mee■■■ ■■.■.■E■■■.■■E.E■EE■■....EEE.■■.E■■.■■■■..■.■.■■■�■■■■■■■■■■■■■�■■ ■■■■■M.■■■■■■■.■.■■1■■■■.■e■.■e■■■■■.■.e........e.■■...M.e.....■EM ■■E.■■.■.E■■■■E■■■■..■■.EE■.EEE.■■■EEE►J■■■■■■■.■■■■.■■■■■■■■■■■■.■ ■■■■■■■■■■■.■■■■■.■■.■■■■EEE■■E■■■■■.■■■■■■■■.■■■■■■■■■■.■■■■■■■■■ ■■.■.■.u■.■M...■....■■.■■■..■.. ■■■■n■.e....E■....E.e...e...=■■■ ■■■.■■■■....■.■■■...■E■E■I■■■■EEE■EE■■.E■.tl■■E■■■■■..■■...■■■■■■..■ ■■■■■■ ■■■■■■ ■■■■■■ ■■■■■■ ■■■■■■ MEMEMENUMMEMEM ■■.■■■ ...■....................,.................1................ 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