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W" __ ' DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTE:Issued in Compliance With Article II of G.S.Chapter 130a
/Sanitary Sewage Systems . 1- Permit er
Name Atp N2
Location ^
VJ��1/. , �1� � /� y'. i/✓. i`, ,` � - �Y''� � ' /' /moi %�- %c1s 1' y�' 17
Subdivision Name Lot No. Sec. or Block No.
/C
Lot Size �� House Mobile Home c _ Business Speculation
No. Bedrooms .No. Baths No. in Family _
Garbage Disposal YES NO ❑ Sec atio s� or stem:
Auto Dish Washer YES NO ❑ L9. y
Auto Wash Ma.hive YES NO ❑ ��� �.'JX i✓r `4J
�✓F'`� . .sem
Type Water Supply __—
'This permit Void if sewage system described below is not installed within 5 year0rom date of issue.
This permit is subject to revocation if site plans or the intended use change.
l
f
Improvements permit by —
"Contact a representative of the Davie County Health Department for final inspection oti"th /system between 8:30-
9:30 A.M. or 1:00-1:30 P.M. on day of completion. Telephone Number 704-634-5985.
T T
Final Installation Diagram: System Installed byal
/gyp
1�
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.
CLEWED
APPLI ATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department AUG 2 7 1992
Environmental Health Section -
( D. R O. Box 665 { L -
( � Mocksville, N.C. 27028
b,
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
. Home Phone
1. Permit Requested By v1 Cb &rt-a ¢ D�0`/-F usiness Phone 09,4--lD-d'
2. Address c _
3. Property Owner if Different than Above
Address ----- - y
4. Permit To: a) Install Alter Repair
b) Privy Conventional Other Type
Ground Absorption M A 'P -TrA CT it
C) Sub-Division Sec.-ff-3 Lot No. 3, 03
5. System used to serve what type f cility: House ✓Mobile Home Business
IndustryOther
b) Number of people
6. ay If house or mobile home, state size of home and number of rooms.
House Dimensions —
t/Bed Rooms Bath Rooms t Den w/Closet
b) If Business, Industry or Other, State: Number of persons served
What type business, etc.
Estimate amount of waste daily (24 hours)
Number and type of water-using fixtures:
commodes 3 urinals garbage disposal
lavatory _3 showers 2— washing machine
dishwasher sinks
8. a) Type water supply: Public Private Community
b) Has the water supply system been approved? Ye �o
9. a) Property Dimensions ;/ /� '9 C ✓ k7C
b) Land area designated to building site )_ D� "y CTY�
c) Sewage Disposal Contractor
10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve?
What type?
G This is to certify that the information is ct to t of my knowledge.
D e Owner Signatu
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
� 1
DCHD(6-82)
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DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
NAME _ / i� � DATE EVALUATED
ADDRESS PROPERTY SIZE �Q
PROPOSED FACIILTY 12�j t 1 LOCATION OF SITE XV e�LZ
Water Supply: On-Site Well t.� Community Public
Evaluation By: Auger Boring L/ Pit Cut
FACTORS 1 2 3 4
Landscape position L L L
Slope %
HORIZON I DEPTH
Texture group S'
Consistence
Structure
Mineralogy
HORIZON II DEPTH
Texture group
Consistence
Structure / /
Mineralogy
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: 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 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
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Davie County Nealtif De artment
and dome NealtFr Ayency
210 HOSPITAL STREET/P.O. BOX 665
MOCKSVILLE.N.C. 27028
PHONE:(704)634.5985
September 3, 1992
Charles McGurer
c/o Potts Realty
P. 0. Box 11
Advance, NC 27006
Re: Site Evaluation
Byerly Chapel Road
.Dear Mr. McGurer:
As requested, a representative from this office visited the aforementioned
site on September L', 1992. The site was found provisionally suitable for the
installation of a ground absorption sewage system.
If you have any questions, please feel free to contact this office.
Sincerely,
Robert B. Hall, Jr. , R.S.
Environmental Health Section
RH/wd
Enclosure