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126 Buchin Ln DAVIE COUNTY HEALTH DEPARTMENT t j IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION *NO4E:Issued in Compliance With Article 11 of G.S.Chapt r 130a S nitary Sewage Systems e Permit Number Name "110 E Da N� - 7657 Location Subdivision Name Lot No. Sec. or Block No. Lot Size L�; House Mobile Home �''� Business -- Industry No. Bedrooms � No. Baths -C:2 No. in Family _ Public Assembly Other Garbage Disposal YES ❑ NO Q'' Specifications for System:/ -I Auto Dish Washer YES NO ❑ " /� Auto Wash Ma^hine YES NO ❑ wo, Type Water SuPPIY *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. 1 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 0� r-- x 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. •� APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT Davie County Health Department Environmental Health Section P. O. Box 665 0�/ Mocksville, NC 27028 /! J U L 181994 1. Application/Permit Requested By rC�/�A°� ` QL _ Mailing Address 0 /st7/ IAQ e!X—,—,oge Z-xw,�F Home Phone V ,��7Yr4Nc. ZY,, 7d0 Business Phone��0` 2. Name on Permit if Different than Above 3. Application for: WGeneral Evaluation WS"eptic Tank Installation Permit 4. System to Serve: ❑ House 2"'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 DKVashing Machine No. of Bathrooms T Dishwasher Dwelling Dimensions aG ' �(. ❑ 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: a Public ❑ Private ❑ Community 8. Property Dimensions Sewage Disposal Contractor �/ 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes o 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. )e 1,1 Directions to Property: MAX-,L &�sawoo • �e° o 2 iC3 � This is to certify that the information provided is correct to the be f my knowledge, and I and stand 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: Ld'1. 1 OWN the property. ❑ 2. 1 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 representative the Davie County H Ith Department to enter upon above described property located in Davie County and owned by'' c to conduct all testing procedures as necessary to determine sit 's suita ility for a ground rption sewage treatment and disp�al system. 2V DATE SIGNATURE DCHD(193) ' DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation NAME �//G //1, DATE EVALUATED 7/2 `�/ ADDRESS PROPERTY SIZE I.Al PROPOSED FACIILTY LOCATION OF SITE Water Supply: On-Site Well Community Public Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3 4 Landscape position L L y L Slope Z — — — HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH -� Texture group 0- Consistence -6-,- Structure E-iStructure 51k& 5_6 �< 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: LANG-TERM ACCEPTANCE RATE: L OTHER(S) PRESENT: REMARKS: LEGEND Landscape Position R-Ridge S-Shoulder L-Linear slopeFS-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-Vory friable FR-Friable FI-Firm VFI-Very firm EFI-Extremely firm Wet NS-Non sticky SS-Slightly sticky Sm-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 ■....■.■...■■■.■..■■■.■...■...../..■■■■■......■eee.■■..■...e■■■i■■ ■■■....■.■.....■.■....■■..■.........■....■■■■.■.■■■■Nee.■■■■.■■■.■ ■■■■■..■...■....■e.■■■..........■e....■■.eee..■...■.■■■■e.■■■.■eM■ ■■.■■■■■■■.■■■■■■■■■■■■■■■.■■■■■ ■■■■■//■/■■.■■....■...../MONO.■■ ■..■■..■■e■................■..■■�..e.e..■■..e....■....Nee.■i..■e■ ■■■..■■■■e■M■■■■■■■■.■■.■■N....■■! 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