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498 Duke Whitaker Rd (2) - DAVIE COUNTY HEALTH DEPARTMENT 1 t'jC t�.ca �\ IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION --*NOTE:Issued in Compliance With Article II of G.S.Chapter 130a -Sanitary Sewage Systems J Permit Number Name �- ,. a 1 } `� �.�'`�'_;;` Date l" N2 8054 Location � _ '0-.r l' �. `v.•.;:.a _�.. «A j)�": },,1.�"ra- �.:Jnti1_dV.n` e� Subdivision Name Lot No' Sec. or Block No. Lot Size � -''_.r. House — Mobile Home _�__ Business -- Industry No. Bedrooms ---.No. Baths —=-'— No. in Family — Public Assembly Other Garbage Disposal YES Q NO d Specifications for System: °k Auto Dish Washer YES p NO / J 00 c) Auto Wash Ma,:hine 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 ATTENTION: YOUR SEPTIC SYSTEM CONTRACTOR MUST SEE THIS PERMIT/LAYOUT BEFORE INSTALLING THIS SYSTEM. 1 rr r , r 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., 1:00.1:30 P.M. or 4:30-5:00 P.M.on day of completion.Telephone Number: 704-634-5985. Final Installation Diagram: System Installed by 611 Ck 1 Certificate of o pletion �_ `a Date o _ 'The signing of this certificate shall indicate that the sys m describ d above has been installed in compliance with the standards set forth in the above regulation, but shall i NO way b taken as a guarantee that the system will function satisfactorily for any given period of time. vJ- C�o�`^�� APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PE Davie County Health Department Environmental Health Section �' P. O. Box 665 JJN 5 Im Mocksville, NC 27028 U ETH 1. Application/Permit Requested By Mailing Address �OX 73l Home Phone 70 q- !22-5,C 32- KS'OZZ 70.2 8-- Business Phone 2. Name on Permit if Different than Above o AWRY Su��l��l 3. Application for: ❑General Evaluation Septic Tank Installation Permit 4. System to Serve: ❑ House Mobile 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 3 Washing Machine No. of Bathrooms ,Z ❑ Dishwasher 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: YPublic ❑ Private _ ElCommunity 8. Property Dimensions /7 Y2 Q, ¢— Sewage 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: 7 / r 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 SMIGNATURE CONSENT FOR SITE EVALUATION 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 ground absorption sewage treatment system. sus DATE ATURE DCHD(1193) ' DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation �j NAME 12> Css�� nom, DATE EVALUATED (y / 3. ADDRESS C2 �` `� PROPERTY SIZE PROPOSED FACIILTY O't1Q LOCATION OF SITE - J3 u VX Water Supply: On-Site Well _ Community Public Evaluation By:Cty Auger Boring 1/ Pit Cut FACTORS 1 2 3 4 Landscape position 5S S Sloe % V-911 R Iso HORIZON I DEPTH Texture group1� V Consistence Structure C2 Mineralogy \ 1 �� HORIZON II DEPTH Texture group C Consistence =t ms's - Structure Mineralogy HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence - Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE '— CLASSIFICATION @ •S LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: \ '� EVALUATED BY: LONG-TERM ACCEPTANCE RATE: OTHER(S) PRESENT: N REMARKS: - �`• �c 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 <;lay 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 .3C--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 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' 1CHD(01-901 ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■�l.■..■■.■ ■■■NONE ■■■■■■■■.■E■■■■■■■■■■■■..■■■e■■■■■■■..■■■■■■.■■■■ MENE■EEMENNO■OM■ ■■■■■■■■■■■■■■■■■■■■■/■■■N■■■■■■■■■■E■■■■■■E ■■M■■E■■E■E!E■■■■ME■■ ■■■■.■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■.■■■■■■■■■■■■■■■■■■■■■■■■■■■■■E■■E■■.■■■.■ ■■e■■■■■■■■■■■■■■■■■■■■E■■■■■■■■■■■■■■■■■■■C■■■M■■.MMM■■MMMMMMMMM■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■M■■■■■. ■■■E■■!■ ■■EEEE■E■■■M■ ■■■■■■■■■■■■■■■M■■■■■■■■■M■■■■.■■■■■■■■■■■.■■■■O■■■� ■■■M■■■■■■E■■ ■■■■■■■■■■■■■■■■■■■■■■E■■■■■■■E■U■■■■■■■■■■■■■■■■■ ■■■■MM■M■■■MM■ MMEMSEMMEMEMEMENOMMMOmommomommommmmmmmmmmmmmm■m MENSIMMMMMEMMMEMEN ■■■■■■e■■■■■■■■■■!■.■.■■e■■C.......■■■■■■■■■■■■C■■eMC■M■■■■■■■■■■■ ■■■■■.■■■■■■■■■■■■■■■■■■■■■■■■■■■■MEMME■MMMmmmi■.■■■M■■i■■■■■■■■■■ MMEEMOMEMMMEMEMENEENMEMMMEMEEMMMMMMMMMOOM CCC C I MEN MMMMMMIMM ■■■■e■■.ee■■■■■■■■■UMomm■■■■■■■■■■■.■■■■M■■■■■.M■ ■■■■!■■■D■■■E■■■ CCCCCCCiCCCCCiiC�liiii,'iiiiiiiiiiiiiC=C■�C.iiiiiiii'u'C■CCCCCCCCCCCCC=C ■■■■■■■■►rir■■��Ntr■1o .I■■e.■■■.e■■■■►tl��r■�■_e■w■■.■.■ i■■■cR■■■►a■■■.1..1� ■■■■■■■■Ilan■■II%l�■■.t■(1..\l■■■M■■■■■■■./.■■■■■NN.H■■■� �■■■\i/■■■■■■�. ■■■...■■lel■�/i.■.►�1�!'■.■Il■■..[�■■/illi%.■■.■■■■.■..� OM�.n..■■■■■ ■■...■■.IJt��::�I��i�!�■.■�%NEON■\■.■..■■■■..■ NOON.■ ■ ■■ ■■ NOON..■ ........►....►.,•..1► MINN ■■■!MM■■!...■■Neelt�i■■uNNE■■MUMN�■■■■N■■■HNNN■■■■■■ ■■NEEM■■ NONE ■I■■■■■■■N■!tl/■■\`�■,�■■N■■■■■■■■■■.■■■■■■.■ ■NON ■■■■■■ MORE IIA■.[ .!! ■.■■IL%.■MC■I.■■■■■■.....■.�...■■MMM ■n NMC:IIMM■MMM= ■■■■I■►`��■�s\lfii��7r:�•w■•.■■■■■■N ■ ■ MEN ■■■■■■ ■■■...1!�r��_'/..��..,�.M�.M■..■.■C�M ■ NOON ■■ ■•�CCNC CE.rim EEM.■ ■■■■.■■.�■�� i.■. 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