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P8117 Clodfelter Ln DAVIE COUNTY HEALTH DEPARTMENT 1V� IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION I *NOTE:Issued in Compliance With Article II of G.S.Chapter 130a Sanitary Sewage Systems $; ,r Permit-Number Name )f>rle 2i G7 `�!r''„s�� f ...! /� — Date .2 -f > N2 81 17 Location /! r Subdivision Name Lot No. Sec. or Block No. Lot Size 1House — Mobile Home Business —_ Industry No. Bedrooms . _.No. Baths — -- No. in Family �^ — Public Assembly Other � Garbage Disposal YES ❑ NO p'' 'Specifications for,System: Auto Dish Washer YES ❑ NO p'` �� r_�`c' �'” `� r' :�Yt"f Auto Wash Ma-hive YES p' NO ❑ -J i // % j , 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. I= Improvements permit by LL *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:704-634-5985.21'/60 Final Installation Diagram: System Installed by 1100 0 / toe - ��12 spy� 787 `s--Y;6 gD Sb - b0 Certificate of Completion — /G�%/ p / _.— 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. R,: 0 TL APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PE Davie County Health Department JUL I 1 10 Environmental Health Section P. O. Box 665 Mocksville, NC 27028ti ;li13TR1 Ff / n �o1nd r`ct �� r 1. Application/Permit Requested By S �f Mailing Address 67S A_a rly -1an r°s �y' Home Phone A/ C a 72 9a Business Phone 2. Name on Permit if Different than Above 3. Application for: ❑General Evaluation Septic Tank Installation Permit 4. System to Serve: ❑ HouseMobile 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 2]'*ashing 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 12 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 ^^//__ El Private J C3 Community on8. Property Dimensi /d a cyt 7�'—� 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: U ►� � �e�� C � oSS 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 a plication. , 77- DATE SIGNAT RE CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY [and ECK ONE: ❑ 1. 1 OWN the property. 2. 1 DO NOT OWN the property. cked Box #2, the rest of this form MUST be completed by the owner or a person authorized by the owner: ive consent to the authorized representative of pe Davie Cou ry ealth epartment to enter upon above described cated in Davie County and owned by t all testing procedures as necessary to determine said site's suitabil for a ground absorption sewage treatment sal system. DATE SIGNATURE DCHD(1193) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation NAME DATE EVALUATED ADDRESS PROPERTY SIZE PROPOSED FACIILTY .L��`.1F� � LOCATION OF SITE Water Supply: On-Site Well _ Community Public Evaluation By: Auger Boring t/ Pit Cut FACTORS 1 2 3 4 Landscape 20sition ,L Sloe % HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH Texture groupL' G Consistence Structure Mineralogy HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture groupt f Consistence Structure Mineralogy SOIL WETNESS I RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: EVALUATED BY: LONG-TERM ACCEPTANCE RATE: 2 OTHER(S) PRESENT: REMARKS: LEGEND ` i 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-V=,ry 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 DCHD(01-901 ■■...■■■.■■......■.....■■■■■.■■■■■.....■......■■■�°■■°°■■■ ■■■...0 ■■■....■■■....■..■■■......■..... °■■■OS■MN■MMS.SSSMSON■■■■■.■■■■■ ■■■■..■....■...■■■■■■■■■■.■ ■■■■■■■■■.......... 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