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132 Cable Ln (2) ` r + S • J'_ DAVIE COUNTY HEALTH DEPARTMENT 160. 'D `" d IMPROVEMENTS PERMIT AND CERTIFICATE-_60 COMPLETION * Sanitary 9 Y II of G.S.Chapter 130a NOTE:Issued in Compliance With Article Sanita Sewage S stm I Permit Number Name •E'T v\x �' u" Date+ r 3 9� N2 TOR Location �iL— .�1� \,� U 5 - y 1 �A s .10 Subdivision Name Lot No. Sec. or Block No. Lot Size_.3 . ��?`s°A House Mobile Home Business : Industry No. Bedrooms .No. Baths— No. in Family-- Public Assembly Other Garbage Disposal YES p NO '[S .-Specifications for System: Auto Dish Washer` .f, YES NO p J 0 v - Auto Wash Ma thine YES Cq} NO p ti U'� : U Type Water Supply v — \ �-- --- *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. ,, 3 ++ 2 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• ..G , 7System Installed by —�Dy /7);/)1-9 �3 fo Certificate of Completion Date •The signing of this certificate shall indicate that the system described Bove 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 --Davie County Health Department ID C7 Environmental Health Section P. O. Box 665 JUN 1Q9 �•q Mocksville, NC 27028 �� Amis Der"--------------- Ong 5 1. Application/Permit Requested By o e/r Mailing Address X Home Phone -1 &ioc h t�d . �'bcA 0 r I to Business Phone NC " 2. Name on Permit if Different than Above 3. Application for: ❑General Evaluation eptic Tank Installation Permit 4. System to Serve: ❑ House O Mobile Home ❑ Place of Public Assembly ❑ Business ❑ Industry ❑ Other ❑ Unknown 5. If house, mobile home:Subdivision Section Lot # ❑ Basement/Plumbing No. of People —7 ❑ Basement/No Plumbing No. of Bedrooms y [)Washing Machine No. of Bathrooms_ ishwasher Dwelling Dimensions q� `f �� • ❑ 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: ublic ❑ Private ommunity OU 8. Property Dimension Sewage Disposal Contractor 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes 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: / 49 ` (T��ds k(lT - 4 . e , /(f Cl 5 =77 AkA� A94 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. (,r', � DATE SIGNATURE CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY Fandd ECK ONE: ®'1. I OWN the property. ❑ 2. 1 DO NOT OWN the property. ked Box#2,the rest of this form MUST be completed by the owner or a person authorized by the owner: ve consent to the authorized representative of the D vie County H I h Department to enter upon above described cated in Davie County and owned by c-/— all testing procedures as necessary to deter aid site's suitability forpagun absorption sewage treatment al system. DATE SIGNXT RE DCHD(1/93) s DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation c, NAME � � 1 y sJ DATE EVALUATED - ADDRESS S Q ti-Q PROPERTY SIZE `f PROPOSED FACIILTY HO tv,,2 LOCATION OF SITE Water Supply: On-Site Well Community Public Evaluation By(�'-AugerBoring Pit Cut FACTORS 1 2 3 4 Landscape position S S -s Slope % 1 S- ' 15ro - - HORIZON I DEPTH Texture groupL C L C�- Consistence Structure Cv >? Mineralogy %) 1. HORIZON II DEPTH Texture groupG Consistence Structure (3 K Mineralogy �• J l: HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON — SAPROLITE :7- CLASSIFICATION - LONG-TERM LASSIFICATIONLONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: EVALUATED BY: M LONG-TERM ACCEPTANCE ATE: L[ OTHER(S) PR NESE T: REMARKS: �1 *" 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 DCHD(01-901 ■■...■.■■■■..■■..o■EEM.E.■.EEEEEEE■■■■EE■■■■■■■■.■■■■■■e■■■■EE■■■■ ■■■■.■■■■■.■■■■■.■.■■.■■■■■■.■■■■■ ■E■■..i.i.N■.■■■■■■.■■■.■■■■■■ ■.■.■..n■EEE.EEEEE■.EEE■ENO■■■■�....■■■■■�■■M■EM■■■■M■■.■■■■ ■■■ ................■......,.......................... 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