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212 Buckeye Trail Loo A ' DAVIE COUNTY HEALTH DEPARTMENT � /U''• �' IMPROVEMENTS PERMIT AND CERTIFICATE .OF COMPLETION *NOTE:-I sued in Compliance With Article 11 of G.S.Chapter.130a Sanitar�Sewage Systems Permit Number Name ' iZ StA N Date `� Cl N2 7492 Locationi-\ a�.i Tai \��.15^.� �\ �.`1 1 Subdivision Name Lot No. Sec. or Block No.–`� Lot`Size�3 House Mobile Home—� Business _— Industry No. Bedrooms "`t No. Bathsz No. in Family _ Public Assembly Other Garbage Disposal YES ❑ NO (p--/ Specifications for System: 2 •Auto Dish Washer YES E( NO ❑ a 0 o Auto Wash Ma:hive YES l/ NO ❑ Type Water Supply *This permit Void if s wa a sy tem described below is not installed within 5 years from date of issue. This permit is subjec to r ''vo ation if site plans or the intended,use change. _ Lu�� y w LA \\ f�J CY O tAA 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. System In Final Installation Diagram: J by � –i Gus Certificate of Completion �\� Date _L '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. v ~' APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT ' Davie County Health Department Environmental Health Section P. O. Box 665 Mocksville, NC 27028 1. Application/Permit Requested By �� C. 0-1 /L/i J G Mailing Address P� 1 111�,,! )�X�3� Home Phone C?9e 01�0 K)C— �-7(� G Business Phone 0 o(0 f—SW7. 2. Name on Permit if Different than Above 3. Application for: ❑General Evaluation XSeptic 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 (D ❑ Basement/No Plumbing No.of Bedrooms1 Washing Machine No. of Bathrooms Y;?, 3 lZ A Dishwasher Dwelling Dimensions `la K 30 - ado �c✓j '" / ❑ 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: ❑ Public Private ❑ Community 8. Property Dimensions 7.3 oLcreS Sewage Disposal Contractor 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes P(No 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: y0 WT 7-0 "F4PJy/1/J67W e04'-4 ¢--•/%, CO A)0a1-H TD /?iOD1A16 �iDC�� D. /AKL ?u00 1�16 �t OC�er iZ3 vP e)f -17M /f/&L A 10 j t4k R16'07 ons '><3uC-kej o f eA i t b fe-eTy t s �T �i - e0 0 o� �� ,40 jA C-�T Tiff �P QZI Y ow n1 q-p ID CkA2�.S e-3dG�Q ons 1-ttti calsis t A-><18 �,,QIA S . �- v,1 6n1 S'� -WC[bS'.0 NMS . This is to certify that the information provided is correct to the best of my knowled e, and I understand I am responsible for all charges incurred3fro this a plication. a6t'®� 7,v DATE SIGNAT CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY MUST CHECK ONE: ❑ 1. 1 OWN the property. ❑ 2. 1 DO NOT OWN the property. If you checked Box#2, the rest of this form MU T be completed by the owner or a person authorized by the owner: I hereby give consent to the authorized representative of the Davie County Health Department to enter upon above described property located in Davie County and owned by 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•(1193) - RN ENCS •CO ER , :CHARLES -.W.. LUTZ � IP . DB.126 PGJ47_ EIPui `. nN 4<3<3 S • _ .. � � _ 6 . . 6304. _ 2 Iry C , -.,'NIP F o AREA = 10.000 ACRES Z N IU BECONVEYEO. . TO - -CHARLES R`. ROGER o PIP RTHUR .J McCASHIN, �iR o u' DB. 144 -PG.75 ti Q o V. 013 PIP N '•AREA 8 3C ACRES 97.: PG,.474 CD �.� AREA pEA=4583' S '� wj''- i � A < x - >• i !-^i••�'. i�. COIU�XEYFA TO.• `' CHARLES'-•R:--�EB• r 'x t•:.$..�-may. L :•.� ., ?. "� "� �t�� , 'S 4i« rs f �. NE 82°55� 19312 1P 39 c �7"w , }' SQf• J DAVIE COUNTY HEALTH DEPARTMENT ., Environmental Health Section Soil/Site Evaluation 2 NAME ` 1"� DATE EVALUATED 1 ADDRESS Q � PROPERTY SIZE PROPOSED FACIILTY \�ovs 4 LOCATION OF SITE . .,.a Water Supply: On-Site Well Community Public Evaluation Byi;-.£- Auger Boring Pit Cut FACTORS 1 2 3 4 Landscape position .S IS, Sloe % o -43� 1.� 1 HORIZON.I DEPTH r Texture group C' L Consistence Structure Mineralogy HORIZON II DEPTH Texture group Consistence �= Structure Mineralogy .1 _771 P i HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS 7,75 RESTRICTIVE HORIZON -- — — — SAPROLITE CLASSIFICATION -5 LONG-TERM ACCEPTANCE RATE , SITE CLASSIFICATION: S EVALUATED BY: LONG-TERM ACCEPTANCE -,RATE: OTHER(S) PRESENT: REMARKS: Gi► - 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-Finn 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(01-901 ■.■■■.■.■.■■..■■..■■t��■aye■.■■■.■■■■■.■■...■.■...■.■.■■.■.....■■.■■■ CCCCCCCCCCCCCCCCCCCC\\ OMEN 0 ■..C.■CCC■C■.■C■■■�.Li\■I1\.�1Cis'C■�3CCCCCCCCCCCCCCCCCCCCCCCCCCCC CCC ■■■■.■..■■.■■■..■.■■I �i,\t'x1.a ilial.■■■■■...■...■■..i■...■�....■.■■...■ mommom ■.■■■■■.■�■.■■.��%■■.\it■■1\.tl./\■..■■.■■■■.■■.■■.■■ H■.■■■e■■■■■C■ ■.■■■....■..■..■...■■..■s:■trot/...■..■..■■...Mi:■.■..■...C...■...■.■ ■�i�iiiC�CCiiiC■�;■CCCCCCoommmm mM1llfiMMml.�SEE iiiiiii.Cji ■■.■■.■■■■■..■■■■■.■■■.■■.■■ .■.■■..■11....■■.■■■■.■■■■tl■..■■■■■■M■ ■■■■...■■■.■.....■.■■■■■.■.�■..■■■...i�u. ��..... ■■C...C.■■C...C.■C.■■■C....C■C.■■.■C■■C..■C...C...C....C■.C.C.....C...C..■C.■■C...C.■e.C.■.C■.�../.■r.■.....■■....■...■..■■..■.......ii'l�� .Cu.C�.■. 0u■.mi■■.■■■■■■■■ t'111.■■■ wMMM11■.C..■.■..■ loss C,ill . ■■1i■■ .■■e■■■■ CCCICCCCCCCCCCC' � :CCCCCENUMECI1NORM" CC OEMC..■■NmI■NM.■.C.■■■ CC■ Me..�- ■..■.....■..■.■■■..■I■■..■....■..■■.■/iiiirlM,� N ■MMMM■■ ■M■■■■ ■ ■■.■...■..■.....■■..%..■.....■..I■O..N��/C!i`�►/■■i� MONO■e■.■■/e■■.■ ■.■■■NMMN■■■■MMM■■MfNMM.NM■M■■■M/MM■■.' 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