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257 Duke Whitaker Rd v .y,:� � _ h .:,:;.r,Y ,,.t a),�' :.*:�'.r'`a9 i'{'Ct.. � { s-1:.� '- i...j Y" •: 'R,G DAVIE COUNTY HEALTH DEPARTMENT op t 'IMPROVEMENTS PERMIT- AND CERTIFICATE OF COMPLETION` _ e *NOTE:Issued in Compliance With Article II of G.S.Chapter 130a Sanitary Sewage Sy tems Permit Number y:n k\ : \ \N\ �.� pIt �, - �� - � 3 No 7157 Name -- Date Location _ Subdivision Name Lot No. Sec. or Block No. Lot Size House — Mobile Home Td Business,_— Speculation No. Bedrooms .No. Baths No. in Family Garbage Disposal YES ❑ NO S ecifications for System: Auto Dish Washer YES . NO ❑ Auto Wash Ma thine YES NO ❑ ;/� ' k i � t� Type Water Supply — *This permit a/oid-tf-sewage system des� �d below is not iastafled within 5 years from date of issue. This permit is subjec to revocation if site plans or the intended use change. C � • �1j r i 0(A t mprovements permit by -- — ' '''mac --- — --------- —..— *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. Telephonq Number 704-634-5988. r �-0 RAJ � — Final Installation Diagram:, System Installed by — ! 14 6 IL _LF'all /00, C_ 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. y APPLICATION FOR SITE EVALUATIOWIMPROVEMENTS PERMIT --�- �--- Davie County Health Department I ` � Environmental Health Section 419M P. O. Box 665 i4 Mocksville, NC 27028 - - s =;JIL COUNTY HEALTH DEPT 1. Application/Permit Requested By & I L O ERT M , L Y P K� Mailing Address ri . 1 j6oX I q S jqDVANCE ✓V' C' c+2 7 O O Home Phone l 3 R — 9 5 2 1 Business Phone 4 g a 0 0 ti 6 2. Name on Permit if Different than Above s a9 3. Application/Permit for: ❑ General Evaluation 1 Septic Tank Installation 4. System to Serve: YHouse ❑ Mobile Home ❑ Place of Public Assembly ❑ Business ❑ Industry ❑ Other ❑ Unknown 5. If house, mobile home: Subdivision Al A Section Lot # ❑ Basement/Plumbing No. of People Z ❑ Basement/No Plumbing No. of Bedrooms N.Washing Machine No. of Bathrooms �� ❑ Dishwasher Dwelling Dimensions Z X .5 Y Q C3 Garbage Disposal 6. If business, industry, place of public assembly, other: Specify type N A 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: ❑ Publicu q V G y P(,4C-SpR®1� K Private ❑ Community 8. Property Dimensions y ncu C S 1-N pCA"cz- Sewage Disposal Contractor 9. Do you anticipate addditions/expansion/of the facility this sytem is intended to serve? Yes ❑ No If yes, what type? 10&5S1,616 /4OM E AG/LT IF 6)(15T1NG- )JoV5C •Do*5n17'svtxiC6 Pok S-•10 WS, *NOTE: Improvements Permits shall be valid for a period of 5 years from date issued. Improvements Permits are subject to t" revocation, if site plans or the intended use change. Effective October 1, 1989. Directions to Property: W Y 6 vv G=S T O vT or /`!0 S �G EI c R o S AFI L(b PAST c6nMTE2 VoL , FIR6 ,06-P`7- d- Thk & J ,. R1017' e I4914A! Ao ) S7,tY S 7'R4IG qy 19PPR DSC. ✓ Hiles 7a DvK6 vjHI rrAKC-R RD , 7-ogAl /QI(� ,aff OvKL - 1vM1TT9N6-Q R.D 4hour t .9Mi1✓c- ro 2. No golvc- oiv L6 N + �,�irc� L0� /avSC) WCL 1,0C4t►� 8(-N/'vo 1IDVSEi , s Eprr— `r61VJ 'J o vt,0 86 o u 7- oP� v O V J/VJ~�E�� 8 PR ka(IS6r Awy, T!vu`rtr : X1 S T�ny�- W t,(, 1 S' I N l'v, f't4vu5 N��v:� 1,+c;raS'6 Hi;w�-uC A Waw w6LL l'11JYBF. AF&VtQEd c lv t6 y, 00, PEw,afl<1fV^ Gx'iS7 t,��t,v LL, This is to certify that the information provided is correct to the best of my knowledge, and I under tand I am responsible for all charges incurred from this anpl�tion. /I DATE SIG TURE CONSENT FOR SITE EV LUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY Fanddisposal 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 groun absorption sewage treatment system. Y DATE SIGNATURE DCHD(12-90) �. DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation NAME S! DATE EVALUATED Jr 43 ADDRESS S 9` PROPERTY SIZE ` PROPOSED FACIILTY o sa LOCATION OF SITE S" W Vz"Ve , �0 Water Supply: On-Site Well Community Public Evaluation By:C�,k- Auger Boring LJ Pit Cut FACTORS 1 2 3 4 Landscape position S' e •--5- Slope Z b -S° 0 -9-0 > 6 C�-T HORIZON I DEPTH 61• Texture group CA- `I- d Consistence Tyz Fs Structure �-'CZ _ 2 C. Mineralogy Z 1 I" 1' HORIZON II DEPTH �' �'' ysah Texture group C Consistence Structure k S K Mineralogy1i HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS SS' SS RESTRICTIVE HORIZON — - SAPROLITE -- CLASSIFICATION S p T7S LONG-TERM ACCEPTANCE RATE ( + ,y 1 NSITE CLASSIFICATION: `zt •S EVALUATED BY: LONG-TERM ACCEPTANCE RATE: 1 OTHER(S) PRESENT: `yOQA REMARKS: ��� C9L,►a `1 °�o•�- ��� �- Cu�A� , 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 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 ■■ecce■■e■■■■■■■■■■■■.■■e■■■■■...■■■■■■■■■■■■■■■■.■■■■■■■■ firr�� ■ NOON■■■■■e■ecce■■■.■e.■■o.■■.■■■�i■■.OM.■■■■■■■M■■e■■■eeeeeee.■■■■ ■■eeeee■■■■■....■e.■■e..■■s.■.■■e■ee■eeeO■e■■.■seNOeee■eeeeeeOM■■■ ■■■■■e■■■■■■■■Nee■■■..■eee.■■.■■■■■■■■■■■■■.■■■■■.s■....■..■.■.■■■ ■■■.■■■■■.■■■ee....■■■■■ee■■ee■■■■■.e■eeee■...M■■■■■.■■■■■■■■M■■■ ■eee■..o■■......ee.■■ee..ee.■■e.■ecce■...e...eeee■.■■■■■■■M■MMee■■ ■■■........■■................■..�■.......■.■■■■Mee.■■■■■■■■■■■■■■ aaaaaaaaaaaaaaaaaaaaaaaaaaaaaa:aaaaaaaaaa'aaaaa:aaaaaaaaaaaaaa:aa ■■■■■■■■■■■■■■.■.■■■.M■■■■■■■■■■e■■■■e.eeeeee■■M■■■■■e■■■■■■eee■■■ ■■e■■ee■■ee.e.O■.■eee■..■■■.e■s■ ■■..■.■.■.■......■..e.■..■ee.ee■ ■■■.■.■■■■■■■■■■.■■■■■■eeeee■■■■�i■■N■eeee...■■■e■■.e■e■■.■..e.■N■ ■■■■■■■Nee■ecce.■■■■ee.e■eeM..e■e■e■■.■.eeMO.N■M■■ ■■■■■■■■■■■■■■■ ■■■■■■.■■.■..■■.■■■■■■.■■■MM■■■■■■a..■■■.■■..H..........■M■■■■mom ■ecce.■N■M■■■ee■■■M■■■.■■■■■■ee�■■■�G■■■■■�■.■■■.■■■■■■■■■■■■ ■■■ ■■..e..■■..■■e....■■....■.■■...■ ..■irOO■e■ ■....■■■■.■■■■.■■■.■■■ ■■■■.■■....■.■■■■■■■■H■.■■M■■■.■■■NYz=a■■■■■■■■■■eM=Mee■■■■e.eN■ ■■eeeeee■ae..■.■■NM■■■■■■■...�:■_eer�..weMe.M■e.eeN■ eaee.■e..■.e■ ■ ■■■■■.■■■■■■■■■M■ee..■■M■e.■■� ace■■■■r�a�::,.ee■■■■■■C■■■■■.■■..■■■■■ ■■.■e.■..■■Nee■■eee■■..■■■■■.�_•�.■■%:;eu■r�■..■■■■.■■.■■.■■■■■■NOON ■■■MM■M■■MM■MMM■MM■■.S■N■M■MO•�aN�M■■■.■..■..■He...■■.■■■.■■■■.■■ ■■■■.■.■.■■■■MMM■N■Ne.e■eeeeeee■■eM■.■■■■■■■■■■■■■■■■■■■..■■■.■■ ■Ne.N■Neeee.eNecce.ecce.■..■■■�e■eeeeeM■N■■■.eeMMM■■ NOON NOON■■■ :.:....:.::::::.::...::..■■.■.:.a■■■.a■:a::....:..:::......:■.:.■ ■■■.e....■.....■..■.........■11...■■.....■eee■...■■■■.■..■■■■■.■..■ saaa■aa:�s:aaa::�a::::aa: : :aa:::�:::::: ::::::�s:::::: ■■.■■..■■■■■■■■.■■■■■■.i ��l.i...■■■.e.e.■e■eee.■ ecce..■e..■..■.■■ ■■■■M■■■■■■■■.■■■■■.■O■■ic■■I�A■■■.Cl�■uelompmInimm ■■■■eee H■■■■■ ■■■■■■■■ ■■..■■....■■.■■■■■.■■M■r�■�M■i��iS..Oc�aMN.■ ■MONS■ ■ ■■.M■■■■■■■■■■ ■..■■■■■■MNM....e.e...M��aa■a::�■■.■©■■■Cle. 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