362 Cana Rd .:, DAVIE COUNTY HEALTH DEPARTMENT
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IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTE_:Issued in Compliance With Article I I of G.S.Chapter 130a _ -
i-Sanitary Sewage Systems / Permit Number
w
Date N2 6 U S 9
Locatiog
Subdivision Name Lot No. Sec. or Block No.
Lot Size —zL1-)(e_2 House Mobile Home Business Speculation
No. Bedrooms — No. Baths No.,in Family,
Garbage
amily,Garbage Disposal YES p NO Specifications for System: ^
Auto Dish Washer YES NO ❑ ��, ;��,% %« � "
Auto Wash Machine .YES NO ❑
Type Water Supply ---
*This permit Void`i sewage s tem described below is not installed within 5 years from date of issue.
This perr7 ' is subje� to revoca 'on if site plans or the/00
intended use change.
b � �
.
Improvements permit b -
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*Contact a representative of the Davie County Health Department for final inspection of this system between 8:30-
9:30 A.M. or 1:00-1:30 P.M. on day of completion. Telephone Number: 704-634-5985.
Final Installation Diagram: System Installed by 1� i —
f
i
purd
Certificate of Completion Date 1J�- _
*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.
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
NAME DATE EVALUATED g�/) ' 7
ADDRESS PROPERTY SIZE
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 Z'
Slope %
HORIZON I DEPTH
Texture group �--
Consistence
Structure
MineralogX
HORIZON II DEPTH '►
Texture group
Consistence
Structure
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 �J
SITE CLASSIFICATION: 76 /7(/ EVALUATED BY:
LONG-TERM ACCEPTA CER E: OTHER(S) PRESENT:
REMARKS: /g /i
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 fine
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
Mineralolzy
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
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�► APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
' Davie County Health Department /
Environmental Health Section ��/
P. 0. Box 665 666
Mocksville, NC 27028
1 . Application/Permit Requested By
Mailing Address
Home Phone !Y?SJ�F� Business Phone
2. . Name on Permit if Different than Above
3. Property Owner if Different than Above
4. Application/Permit For: 0 General Evaluation 91-OS/Tank Installation
5. System to Serve: 0 House ? Mobile Home 0 Business
Industry Other 0 Unknown
6. If house, mobile home: Subdivision Sec. Lott
No. of People Dwelling Dimensions
No. of Bedrooms O Basement/Plumbing
No. of Bathrooms Basement/No Plumbing
Washing Machine Dishwasher Garbage Disposal
7. If business, industry, 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
S. Type of water supply: Ile 0 Private 0 Community
9. Property DimensionsC
10. Sewage Disposal Contractor _J/L ! -,w�
11 . Do you anticipate additions/expansions of the facility this system is,
intended to serve? 0 Yes 0 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.
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 applic tion.
Date Signature
Directions to Property :
DCHD (10-89)