701 Duke Whittaker Rd (2) DAVIE COUNTY •HEALTH DEPARTMENT t
IMPROVEMENTS PERMIT AND .CERTIFICATE OF COMPLETION
*NOTE:Issued in Compliance With Article II of G.S.Chapter 130ad
Sanitary Sewage Systems Permit Number
Name ���_� �. �� �. <, �. .� �, — Date — N2r-
6544,
Location
Sub 1vision ame Lot No. jSec or Block No.
Lot Size House Mobile Home _liBusiness Speculation
No. Bedrooms No. Baths 'No..in Family _
Garbage Disposal YES_❑ NO ❑ Specifications for System:
Auto Dish Washer YES ❑ NO p p U
Auto Wash Ma shine YES p' 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.
Improvements permit by
*Contadt 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,—�"-11 R C -TI%
1
W
r
Certificate of Completion ''��� Date 14
'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 PER
Davie County Health Department
Environmental Health Section
P. O. Box 665 r^°•;. - ,
Mocksville, NC 27028
1. Application/Permit Requested By P LMS C A
Mailing Address e el A
c7)-- 7 O6 Business Phone
one
Home Phone I_
2. Name on Permit if Different than Above i- , C- � a
3. Application/Permit for: General Evaluationeptic Tank Installation
4. System to Serve: Elobile House Home ❑ Place of Public Assembly
❑ Business ❑ Industry ❑ Other ❑ Unknown
5. If house, mobile home:Subdivision Section Lot#
❑ Basement/Plumbing
No.of People ❑ Basement/No Plumbing
No. of Bedrooms `_ Washing Machine
/
No. of Bathrooms`A ❑ Dishwasher
�1
Dwelling Dimensions C�o k w ,r ❑ 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: ublic ❑ Private ❑ Community
8. Property Dimensions Q C ire _S Sewage Disposal Contractor �--
9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes tl�vo
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.
�/�I�e ll ( I J
Directions to Property: TQ ` �o P y )N 40 ( CVl u..i'C(n r) ad Aj-�4
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4a� e 1 P-4 jo a.too rr) it P-
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G 1J�O G
�—Y 12 -�-i (`S`1" �('O•` �� t� O f'1 �i Q til
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.
DATE SIGNATURE
CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY
MUST CHECK ONE: ❑ 1. 1 OWN the property. U-1261 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 representat•v"f the Davie Qoyn�y He I�h D partment to enter upon above described
property located in Davie County and owned by t���� W l7 t0- 1' v
to conduct all testing procedures as necessary to determine said site's suitability for a ground absorption sewage treatment
and disposal system.
DATE SIGNATURE
DCHD(12-90)
- ` DAVIE COUNTY HEALTH DEPARTMENT
` Environmental Health Section
�-� Soil/Site Evaluation
NAME - -��.,� DATE EVALUATED
ADDRESS S r"'� PROPERTY SIZE �9
PROPOSED FACIILTY LOCATION OF SITEa
Water Supply: On-Site Well Community Public
Evaluation Byt.'0- Auger Boring Pit Cut
FACTORS 1 2 3 4
Landscape position S S
Sloe Z -J ° -
HORIZON I DEPTH e. C`'
Texture group L
Consistence
Structure
Mineralogy
HORIZON II DEPTH L 1 -1 4 ti' 4 a."
Texture group C. C C-
Consistence Z- V L- T—�'
Structure It!6 '10\3 r—
Mineralogy
HORIZON III DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS 5 S 5-5
RESTRICTIVE HORIZON
SAPROLITE — -
CLASSIFICATION S 5 S S
LONG-TERM ACCEPTANCE RATE �g- yo 39- ,V\1 79-77A ;35 - .yQ'
SITE CLASSIFICATION: EVALUATED BY:
LDNG-TERM ACCEPTANCE RATE: OTHER(S) PRESENT: 'k- o N�
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
Mineralo►
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(O1-901