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1035 Eatons Church Rd DAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION *NOTE:Issued in Compliance With Article 11 of G.S.Chapter 130a Sanitary Sewage Systems Permit Number Y 7013 Namenate = ' NO Location Subdivision Name Lot No. Sec. or Block.No. Lot Size �n__Zll L House �� Mobile Home _T Business Speculation No. Bedrooms No. Baths -as� �� No. in Family — Garbage Disposal YES �NO ❑ Specifications for System: Auto Dish Washer YES NO ❑ Auto Wash Ma shine YES _NO ❑ 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. �� rl ------------ J 4 �. J. Improvements permit by 'Contact a representative of the avi County Health Department for final inspection of this system between 8:30- 9:30 A.M. or 1:00-1:30 P.M. on da of completion. Telephone Number 704-634-5985. Final Installation Diagram: System Installed by IL 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. L_. APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PER ( "VED Davie County Health Department u� I� Environmental Health Section JAR9; 093 P. O. Box 665 Mocksville, NC 27028 +......._ 1. Application/Permit Requested By. % &1J P, � x•11 01 / �G� 44-A-1;1\ Mailing Address i12. r2 Home Phone Business Phone 2. Name on Permit if Different than Above 3. Application/Permit for: ❑ General Evaluation Mr Septic Tank Installation 4. System to Serve: House ❑ Mobile Home ❑ Place of Public Assembly ❑ Business ❑ Industry �r1 ❑ Other El Unknown 5. If house, mobile home: Subdivision Q1t:lP 'i!A-C/,< t7 Section Lot# ❑ Basement/Plumbing No. of People 2 ❑ Basement/No Plumbing No. of Bedrooms 3 0 Washing Machine No. of Bathrooms 2 ;2- Dishwasher. ✓✓ tf3 Dwelling Dimensions�;lp A -Z0 0 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 -2 a 0— Sewage Disposal Contractor 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? [9 Yes ❑rC No If yes, what type? Q aQ 52 *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: U RL' �0 �51-L ?off 1Z s r7ow This is to certify that the information provided is correct to the best of my knowle e, a I understapd I am r risible for all charges incurred fro his application. f DATE SIGNATURE CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY Ftaonddisposal 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 system. DATE SIGNATURE DCHD(12-90) z W u5 3 O nt r) spike m\ cif) 9 C!•. ,. P\k N nail . y� 0 CO 0 \\R�qO ui O tip �I ftI ICJ u) a s LL 181.9��y . n rN 831 - / tJ ,S �. CLARENCE STIMPSON DB. 97 PG. 634- D13. 90 PG, 63 v 1 �v DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation NAME /.vy! j DATE EVALUATED :21Y�� ADDRESS PROPERTY SIZE ;, o S LOCATION OF SITE PROPOSED FACULTY ,. Water Supply: On-Site Well Community Publicy Evaluation By: Auger Boring Pit Cut FACTORS I 2 3 4 Landscape position Slope ^ HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH Texture groupC G Consistence Structure Mineralogy HORIZON III DEPTH Texture grouR Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE t �� SITE CLASSIFICATION: EVALUATED BY: jZ/;'e�z 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 watef 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 ■■.■■■.■■..■...■■.■■■..■■■■.s..■..■■O.00..00.....■■■■.■■■■■■■.■■■■ ■■■■■■■■■....■.■■■..■■■.■■■..■...■.■NOON■.i.....■■...■■■■...■.Ol.■ ■■■■■■........■.■...■..■■■..■■■■�■NOON■.■..................i■■.■■ ■■■■■■■H■■O■■■■■■■■■■■■■.■■■■■■�■■■■■■■■■■■■■■■■■■■.■■■■■■■■ ■■■ ■.sseO..■.O■...00■....■■..O..O..00■■OO.■■.■...■.■.■.■..■..■■■O■Oa■ siiiiiiiiiiiiiiiiiiiiiiiiiiiiii■_��■■..NN..■Ne..e.O...■.■■■ ■....■...■....■.■■..■e..■exec:w■.■..■.■■■■�i■■■■.■■■..■■■■C.■■■■..■ MEMNONMENNEN� MENNEN MEMNON .iiiiiiEMERIM MEMEMN ■...■■■■.■..■..■..■■.....rine■■..■■..�■.......■.■■..■......._.■■■ ■■.........■■■.■■■■.......■■..■.er■■■..........e....■■.■.■..■ NOON iiiIMMOMEN MENNEN 0 ■■..........N■■■.■■Nee■O...ON..■�N....■..■■.■.e ..�■....N..■.■■.■ MEMEMEN MEN��ri��\�� ■■■■■■....■..■■■■■■■■■■■■■.■■O.s■■O.■■■.■■.■..■■O..N■■.■■HON■.■■■