502 Foster Dairy Rd r• +.'.k ?ice d . '.Cyt y., C v. zee^r ,s- `:r S"'� f('
DAVIE COUNTY HEALTH DEPARTMENT uJ3
IMPROVEMENTS PERMIT AND .CERTIFICATE OF COMPLETION
d K
' *N'OTEAssued in Compliance With Article 11 of G.S.Chapter 130a
Sanitary Sewage Systems �iPermit Number /z),j�
Y•
Name �1'�P� /*� `17 dC ate , �� jI NO 1
661
Location '''> [', -
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 ❑ NO p-'
Specifications for System;
Auto Dish sher. YES NO
Auto Wash Ma h ne YES NO ❑ ,� �::� °'/�: r¢ :�' / j„ ` ✓J �%'
GY '�
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.
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. or 1:00-1:30 P.M. on day of completion. Telephone Number 704-634-5985.
Final Installation Diagram: System Installed by -o ?n
- r I'+• /1 , X1.4 �'S.IT
Certificate of Cemple ion l Date f�"� , t
'The signing of this certificate shall indicate that the sysitem escrib d 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 J'
P:O. Box 665
Mocksville, NC 27028
1. Application/Permitquested ByeDe
Mailing Address c-\ 4,u-% a7a0 g-
Home Phone Business Phone J Q
2. Name on Permit if Different than Above
3. Application/Permit for: eneral Evaluation Septic Tank Installation
4. System to Serve: House )S�Mobile Home ❑ Place of Public Assembly
❑ Business ❑ Industry` /�, ❑ Other ❑ Unknown
5. If house, mobile home: Subdivision r `� v '' Section Lot#
❑ Basement/Plumbing
No. of People Dkoasement/No Plumbing
No. of Bedrooms mashing Machine
No. of Bathrooms dishwasher
Dwelling Dimensions —? ❑ Garbage Disposal
r
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 2 Private ❑ Community
8. Property Dimensions Q ✓Q`c� , e wage Disposal Contractor
9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes XNo
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: g
fmcysv. Ile
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I
fCAes..
Wh►�2 Mo..rke�s (�'re-�o� �n�b�Iehe�rnQ
1�--`� �j�\1 CSC• O Y'1 S�C�L'. b� �„ x �
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This is to certify that the information provided is correct to the best of my know edge, and I understand I am responsible for all charges
incurred from this application.
/aa /9 -
DATE SIGNATURE
CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY
FLanddisposal
ECK ONE: 1. I OWN the property. ❑ 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:
ve consent to the authorized representa__t,uucce of the D vie County Health Department to enter upon above described
cated in Davie County and owned by JAIMo6 bla-TC(es -� i(Y\Q E C:5
all testing procedures as necessary to determine said site's suitability for a gr and absorption sewage treatment
syst M.
DATE SIGNATURE
DCHD(12-90)
z
1
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
NAME �5 DATE EVALUATED
ADDRESS PROPERTY SIZE
PROPOSED FACIILTY z&a�2�12,4,xrel LOCATION OF SITE
Water Supply: On-Site Well Community Public
Evaluation By: Auger Boring Pit Cut
FACTORS 1 2 3 4
Landscape position L 4—
Slope
—Slo a % — - —
HORIZON I DEPTH
Texturegroup
Consistence
Structure
Mineralogy
HORIZON II DEPTH t e 410 �-
Texture groupC
Consistence
Structure f /
Mineralogy 4
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 fine
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
Mineraloity
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 watei,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
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