P7689 Clodfelter Ln 101
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DAME COUNTY HEALTH DEPARTME
IMPROVEMENTS PERMIT AND CERTIFICATE, OF COMPf I N
*NOTE-Issued in Compliance With Article I I of G.S.Chapter 130a
Sanitary Sewage Systems Permit Number
Name }�1�V c� cr J Ata 4fi. W�.� Date _ IJ 9 L,, vb
- , }, - 7,589
1 a9
Location' >` _ 5� � `� �9J:<as ^� �� ,�: �! .
Subdivision Name Lot No. S
Lot�Size Houser, Mobile Home_ Business Industry
No. Bedrooms _.No. Baths No. in Family Public Assembly Other
Garbage Disposal ' YES ❑ NO
Secifications for System: .^� t
Auto Dish Washer, " YES ❑ NO p' OO d �� ,.
Auto Wash Ma^hine YES NO ❑ t
-Type Water Supply _ �o c, ..5'S --- Q(a ?✓ ,2;1► `^
- i
*This permit Void if sewage system described below is not installed within 5 years from date'ol issue.
This permit is subject to revocation if site plans.or the intended use change.
1
Q S
Ir,o
. 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
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 betaken as a guarantee that the system will function
satisfactorily for any given period of time.
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PE �������
Davie County Health Department QUG h 1� �9�
Environmental Health Section u
... ... ...... .. ... .... .
P. O. Box 665
Mocksville, NC 27028
1. Application/Permit Requested By ./ / '�' Qa_ 4ecit5 �c
Mailing Address X-7r � ,r1 Y T�/m ps R Home Phon� f, � a
gtl.5F X )�of /1 /V C a^7 2-9;L Business Phone
2. Name on Permit if Different than Above
3. Application for: ❑General Evaluation R-9eptic Tank Installation Permit
4. System to Serve: Elff/House Mobile Home ❑ Place of Public Assembly
❑ Business ❑ Industry ❑ Other ❑ Unknown
5. If house, mobile home: Subdivision Section Lot #
❑lBBasement/Plumbing
No. of People 1 4BBasement/No Plumbing
No. of Bedrooms PWashing Machine
No. of Bathrooms ❑ 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: R-frublic ❑ Private ❑ Community
8. Property Dimensions 070 Amu'" Sewage Disposal Contractor
9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes ❑ 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:
v. �— I�:"GSL 411 —,,e6 t 0 40
Awt&lAt.4oc 474-
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 SIGNATURE
CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY
Fanddisposal
ECK ONE: ❑ 1. I OWN the property. Imo. I DO NOT O ]ib
ked Box #2, the rest of this form MUST be completed by the owner or a person authorized by the
ve consent to the authorized representative of�he Davie C,gunfy Health Department to enter upon cated in Davie County and owned by all testing procedures as necessary to determine said sites suitability for a ground absorption s
system.
DATE r �°� SIGNATURE
DCHD(1193)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
p t
Soil/Site Evaluation
NAME �� '^ �� �e � DATE EVALUATED
ADDRESS � '�'�'�
PROPERTY SIZE
PROPOSED FACIILTY \Xb 'tr"Ns) LOCATION OF SITE
Water Supply: On-Site Well Community Public
Evaluation By�Z'�,:1— Auger Boring ✓ Pit Cut
FACTORS 1 2 3 4
Landscape position S �`
Sloe 7. S"
HORIZON I DEPTH
Texture groupC L
Consistence r 1- rS
Structure G R b R
Mineralo " � 1 !'. I ))' 1
HORIZON II DEPTH L a't . 11
Texture groupC C
Consistence
Structure \ >vs
Mineralogy
HORIZON III DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS tSS 5
RESTRICTIVE HORIZON r—
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE , U L_
SITE CLASSIFICATION:
Q �� EVALUATED BY: c� �
LONG-TERM CCEPTANCE RATE: L1. OTHER(S) PRESENT: o
REMARKS: - —7""' _ �.
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-Vt3ry 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
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
DCHD(01-901