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179 Fairfield Rd ,-k'J r•y+ , s1^..,,.1.E. e i t*�,..1r .s-: rr..... �..0; i Y .:Y., .� Y, r'r -, " `=<t{J _.'t `:..;a' o 1 DAVIE COUNTY HEALTH DEPARTMENT C IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION *NOTE:Issued in Compliance With Article II of G.S.Chapter 130a `Sanitary Sewage Systems , Permit Number �� «��- s No 7032 _ �,r's'c, S f d`/'F�r�'`�J"%' ..:: �-- ,�/i•/,' c .� . Name . Date 4!G'%i/�J //n 1` F' .ff,'%1 I f j ir��j�(/ 'r'i✓�✓� �� ,/�.:'`: .✓' "�..1,"�Ii/�x "r'�'�.�' /r j" Location 4. ,Subdivision Name Lot No. Sec. or Block No. Lot Size House Mobile Home �'"r Business -- Speculation No. Bedrooms `'` No. Baths _ � No. in Family _ Garbage Disposal YES ❑ NO [�� Specifications for,System: Auto Dish Washer YES4 NO ❑ J ';� Fr`/� �`' .!/ /{jGL Vii: Auto Wash Ma^.hine YES E) NO ❑ ✓ GSC% , , ;��� Type Water Supply r *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. 1m rovements 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 704-63f5985. r Final Installation Diagram: System Inst Iled by /DJ w r -;2 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. 13 APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT Davie County Health Department Environmental Health Section P. O. Box 665 Mocksville, NC 27028 1. Application/Permit Requd By, Mailing Address r(� `t/c / Home Phone x`f Z Business Phone '- 2. Name on Permit if Different than Above 3. Application/Permit for: ❑ General Evaluation Septic Tank Installation 4. System to Serve: ❑ House lobile Home ❑ Place of Public Assembly ❑ Business ❑ Industry ❑ Other ❑ Unknown 5. If house, mobile home: SubdivisionMCS b J e Vo Section Lot# ❑ Basement/Plumbing No. of People ❑ Basement/No Plumbing No. of Bedrooms ashing Machine No. of Bathrooms ishwasher 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 ❑ Private ❑ Community 8. Property Dimensions . 75 S Sewage Disposal Contractor 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes i�lo 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: O S© 4k oq r-,,o bt 3 �� 1 ! a_- 5 Gni t' �tc� \\� • -Z /b�eti�1.1 S o� 3 0U tw(e, ©/� 1r e, ,� l �' • � �^-a o o�e c� Q��cam.. �`� s � (� �'Je�r w Q e 1-%- 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. !� 9—U, �J DATE SIGNATURE CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY F- DCHD ECK ONE: ❑ 1. 1 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 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 (12-90) A ' DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation NAME ( (9�'/�' �/ DATE EVALUATED ADDRESS PROPERTY SIZE ',�1�� PROPOSED FACIILTY //� ✓ /- LOCATION OF SITE � �1� Water Supply: On-Site Well Community Public_L____1' Evaluation By: Auger Boring 41___ Pit Cut FACTORS 1 2 3 4 Landscape position Slope HORIZON I DEPTH 1 Texture group Consistence Structure Mineralogy HORIZON II DEPTH Texture group Consistence Structure Mineralogy i / 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: 4/ 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 Mineralolty 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 ■..■■■.n■■■.■■■.■■■..■■■■■...■■ ■■■ine■■■■■■■■■■■■.■■■■■■■■■_■■■ ■■■■■■■■■■■■■■■■■■■.■■■■■■■■■■%'If�■■■L�■■■■.■■■■■■■■■■■■■■■■■■■■■■ ■■..■■■...■■■■..■■■■■■■■Ci�i���■■■■.■�.�■■►\■■■■■.....■■■■■.. ■.■■■■■■ MMEMEMMEMEMMEMEMEMEMEMEMOMME■NEMEMENEMEMEMEMMONE ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ :CCC: :C:':::NNEMC :CC::. ■ : . ■ ........................................................ ........ ::::CCC"CCC'CCCCCCC�:CCCCCC: ::CCCCCCCC:CCCCCCCC::CCCCCCCCCCCCCC ................................ ................................ .........■........................................................ ■■■■..■■■..■■■■■■■■.C........... ................................ ■■■■■■■■■■■■■■■■■■.....■■■■■■■■■e■■■■■■■■■■■■.■■■■■■■■■■■N■■■■■■■