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288 Cana Rd vN a-. .p ,-...- .. ,� .�aYi q,..r.:. 3rs�'...F.ri.:c'N.T:�� .y_-..� y�„:,t `;�•es�l. s.^lv ' `l � .''`C; . ."• 'f-i>- u. .-� ,-. J.. .. .:;.. y DAVIE COUNTY HEALTH DEPARTMENT /00, IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION .-*NOTE:Issued in Compliance With Article II of G.S.Chapter 130a °I STitar�Sewage��`S,y M\\S J 1�� _ �� _ Permit,6t�lw}>tb�ar T . �� Date Np b 4 U Name -, Location Subdivision Name Lot No. Sec. or Block No. Lot Size House + Mobile Home Business —_ Speculation No. Bedrooms No. Baths No. in Family. — Garbage Disposal YES ❑ NO Specifications for System` Auto Dish Washer YES p NO �`;c�- Auto Wash Ma thine YES j NO p 1�pc ;' X 3 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. 1 LL - f' I o t, 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. or 1:00-1:30 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 be taken as a guarantee that the system will function satisfactorily for any given period of time. 4 APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PE MIT.-- -- v Davie County Health Department Environmental Health Section P. O. Box 665 T 2 4Q4� Mocksville, NC 27028 1. Application/Permit Requested By. Mailing Address—A:�—L d3a 1. 3 -) 3 Home Phone ? 7 Business Phone 2. Name on Permit if Different than Above 3. Application/Permit for: ❑ General Evaluation D-Septic Tank Installation 4. System to Serve: ❑ House 2-Mobile 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 ❑-Washing Machine No. of Bathrooms ❑ Dishwasher Dwelling Dimensions -5 ❑ 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: El Public �1 Private ❑ Community 8. Property Dimensions Q C . Sewage Disposal Contractor 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes 0No 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: 1 711 rl h A M4 d, 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 SIGNAT14RE CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY randdisposal ECK ONE: 0T. 1 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 Davie County Health Department to enter upon above described cated in Davie County and owned by all testing procedures as necessary to determine said site's suitability for a ground absorption sewage treatment system. DATE SIGNATURE DCHD(12-90) i DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation NAME Re jj�t _S DATE EVALUATED ADDRESS S Q.Cir 4 PROPERTY SIZE o� PROPOSED FACIILTY \X, LOCATION OF SITE 4 Water Supply: On-Site Well kel Community Public Evaluation By<��L Auger Boring Pit Cut FACTORS 1 2 3 4 Landscape position Sloe 7. d S° a-8 0.:132. O -*go HORIZON I DEPTH " ) 11 Texture group C L- C L-- L Consistence Structure Mineralogy HORIZON II DEPTH Texture groupC C Consistence Z Z F L F Structure B F-5-77-- Mineralogy K Mineralo HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON — — SAPROLITE — — - CLASSIFICATION SI pS FI LONG-TERM ACCEPTANCE RATE +4 47-1 SITE CLASSIFICATION: Y. s LA EVALUATED BY: LONG-TERM ACCEPTANCE RATE: OTHER(S) PRESENT: REMARKS: T 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 t 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 Mineralolty 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 eeeee■■■a■■eee■■■■■Ii■.e■I■■■■■■■■■■■■■■■e■■■■■■■■■11■■.■[1■■■■■■■■■■■ eeeee■■■■s■■■■■■■■■i■■■■Iris■■■■■■■�■.■■■■■■■.■■■■■rle■■elleee■■■c.■■■ ■..a■..■..e.....e..�e..�l.aea.ee■c■tee■■eee■■e■.e.11■■aell..■ee...e.■ ■..........■.....e■..■■�i....■■...■cee■■■eeee■■eee�leae■Ilee.e■.e.■■■ ■■.■eeeee■■■eae...e■■■■I1..■■1/■■■.■eee.■.eye■■....�I....Il.....■■...■ ■.■e.■■■.a...■■....eee.■i.s.rie■er►��caee■■■u.e�■eetl.eeeileeea.■■■■ee ■■■■■■■eeeeee■.■■ac■...trlee■►I■■el�Yii■�■■■�■■■■ ■■■Ile■e.l!■■■■■■■■■e■ ■.ee..a.ee.eee.■eee■eeeIIe.■'I■■■■■■■e.■■.■�e.ee.eeellee.elleeeeeee■■■■ ...ee.eeee■e..e..ee.eaell�.Ileo■■e■■■e■e■t .■eeeeeetle■■■I!e■u■■e■■e■ ■.■■eee.eee.eeeeee.11e.ee,■..ecce■■elrye■■■■■■■■■■■■1!■■■.I■■■■■■■■■■■■ ■.■.■■■■.■.■■■eee■.■■e�.1►■■■■e■■�■■■■■.■■■■■■ee.l/■■■■I!■■■■■■■■■■■ ■■■■■■■■■■■■■■e■■■.■►\■Ilel1\eeeee■ ■..�=====5iii�:r■■■■■I■■eee■■c■■■■ ■■ ■■ ......■..•••••••t•-----------------■/et ■.11ee.e IMMMERIMEMEMEM NOOSE ■■■..■■.■■■■■■■■■■.■■..■■■■■■■.■..■■■.■�■■■1■■.c■I■■■a■■■■..■■ ■■aaee...e..aae.■a...aaee..■.■■■ ■..■.aeeeeeeee■ieseee;■.e■eeeee■■■ ■ea■a■■■ ■....... ....... ■■=ea■a.■eee.ee..■.■..■e.eeeee.e,■..■■l1..■■.■■■■a■ ■■ue.■.■■ ■e■■a.a.e.s...■■■.e..ea.■�■e.U...■■�.......■..■ ■.e■ .........e.■■eeeo■■■.■ee..■■e■■■■■.■a■��■r��■■■.■.eee..eee■■■ C:::::::8::'■: : .".:::'.: ::::: .:::'. s :::::::�::: ::CC:C ■ee....e■n■■ea e�l►.�c•■er.�:�e■es.��■■■■�►�■■ee■■■.■■■�i■■■eei■■■■■■■■■■■ eee.ce.eeii■■a■ ..N.�:'1►�.n''7rwe.■ ��.rlre�i>t r■••••'�..■■�eeeaaa�■eeeee.eee■ ■ca■.... 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O. Box 665 8 Mocksville, N.C. 27028 9 CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED. l Home Phony `T 7 1. Permit Requ ted RV < f S Business Phone 2. Address Mo \j I n C 2707-Sr 3. Property Owner if Different than Above Address 4. Permit To: a) Install ✓Alter Repair b) Privy Conventional Other Type Ground Absorption c) Sub-Division Sec. Lot No. 5. System used to serve what type facility: House Mobile Home✓Business IndustryOther _ b) Number of people S 6. a7 If house or mobile home, state size of home and number of rooms. House Dimensions Bed Rooms Bath Rooms Den w/Closet b) If Business, Industry or Other, State: Number of persons served What type business, etc. Estimate amount of waste daily (24 hours) 7. Number and type of water-using fixtures: commodes -2 urinals garbage disposal lavatory showers .2 washing machine dishwasher 1 sinks �- 8. a) Type water supply: Public Private Community_ b) Has the water supply system been approved? Yes No 9. a) Property Dimensions• 2 ami b) Land area designated to building site c) Sewage Disposal Contractor 10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve? What type? This is to certify that the information is correct to the best of my knowledge. 3 Sly a4414��2 Date Owner Signat re OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS Allow 5 days for processing Directions to property: 601 C� DCHD(6-82) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. 0. Box 665 Mocksville, N.C. 27028 SOIL/SITE EVALUATION Name Date - � A Address Lot Size FACTORS AR A l ARE 2 ARE63 3 E 4 1) Topography/Landscape Position PS PS PS U U U U 2) Soil Texture (12-36 in.) Sandy, [�E5' �S-, �P <•-�� Loamy, CI , (note 2:1 Clay) �, U U U U 3) Soil Structure (12-36 in.) la a Soils p� PS U U � U 4) Soil Depth (inches) S PS PS PS PS U U U U 5) Soil Drainage: Internal � . -It� 4 -t U U U U External � PS -ks U U U 6) Restrictive Horizons 7) Available Space PS PS \ PSS b-� U 8) Other(Specify) S S S S PS PS PS PS U U U U 9) Site Classification U—UNSUITABLE S—SUITABLE (-!' Provisionally Suitable Recommendations/Comments: — _c' easy �` Described by �` � Title � � Date L - SITE DIAGRAM ops. i DCHD(6-82) �'