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DAVIE COUNTY HEALTH DEPARTMENT �` �" `�° U
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTE:Issued in Compliance With Article 11 of G.S.Chapter 130a
Se5tary SeeE� age Systgm n r� �' _ 3 ) ' Perrmi�TV
of
Name U k Date Now
- Ij � � o'!f j L�9 - t1 AJQ .
Location \\ r ,,�r
rosr�.... \ ( �d 1 �� Cl r� ? its
division Name Lot No. Sec. or Block No.
� G.rstet':,, ✓,
Lot Size ''`House ' Mobile Home F Business Speculation
No. Bedrooms :No. Bathsy �" No. in Family
Garbage Disposal ; YES` NO Q S i 'ct
Auto Dish Washer YES kN0 ❑ h � " D-
Auto Wash Ma:hive YE 0 ❑ 3 o C1 �( 3 x 1 }�.�'�Z•
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.
Iov
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r
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. r'
Final Installation Diagram: System Installed by
F, f4
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U F I
lit/
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Certificate of CompletionDate
'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.
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36--a
0� APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department RECIEW 1
Environmental Health Section
_.._.... _.
'P. O. Box 665 -
Mocksville, NC 27028 J :� �g
1. Application/Permit Requested By j !k e
Mailing Address I C/✓•4 ,Jc e- it/.
Home Phone 7!c'-i 9 C-- IftbE?`739- Business Phone 9119—`?9 g= X33
2. Name on Permit if Different than Above . O� 'v 4!!f o Q,4 N
3. Application/Permit for: "eneral Evaluation ❑ Septic Tank Installation
4. System to Serve: House ❑ Mobile Home ❑ Place of Public Assembly
❑ Business ❑ Industry ❑ Other ❑ Unknown
5. If house, mobile home: Subdivision Section Lot#
R'Basement/Plumbing
No. of People ❑ Basement/No Plumbing
No. of Bedrooms 3 -Washing Machine
No. of Bathrooms 2 Dishwasher
Dwelling Dimensions S K SCA ❑ 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: ❑ Public R'Private ❑ Community
8. Property Dimensions G+A C r es 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:
(��d d� �►� �2 , ale ,�d -f (2 40 a ��,•�e
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.
�2- -?- Z11 —
DATE SIGNATU E
CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY
Fandd
ECK ONE: ❑ 1. 1 OWN the property. •�. 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 representati of D vie C uniy Health Dep ment to enter upon above described
cated in Davie County and owned by e�5f e she Al yX$f ,�Y i✓
all testing procedures as necessary to determine i s te's su tability for a ground ab orption sewage treatment
al system.
C?_�
DATE SIGNATURE
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4 DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
f r Soil/Site Evaluation /
NAME
i� DATE EVALUATED
ADDRESS PROPERTY SIZE lye--
PROPOSED FACULTY LOCATION OF SITE ��i9-�/ �e✓ f r
Water Supply: On-Site Well Community Public
Evaluation By: Auger Boring Pit Cut
FACTORS 1 2 3 4
Landscape position
Slope %
HORIZON I DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH i' f" 4d (-
Texture group
Consistence
Structure
MineralogyI•
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 _7
SITE CLASSIFICATION: /"^' EVALUATED BY: ��
LONG-TERM ACCEPTANCE RATE: OTHER(S) PRESENT:
REMARKS:
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
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rDavie County NealtFr ISen
artment
and .dome Nealt§i cy
210 HOSPITAL STREET/P.O. BOX 665
MOCKSVILLE.N.C..27028
PHONE:(704)634.5985
August' 2, 1993
S. Gray Logan
C/o Gilbert L. Boger
Rt. 1, Box 569-A
Advance, HC 27006
Re: Site Evaluation
Clayton Drive
Dear Mr. Logan:
As requested, a representative from this office visited the aforementioned
site on August 2, 1993. Based upon the information provided on the application
for a site evaluation and after an evaluation vas completed, the site vas found
to be provisionally suitable for the installation of an on-site sewage disposal
system.
If you have any questions, please feel free to contact this office.
Sincerely,
Robert B. Hall, Jr. , R.S.
Environmental' Health Section
RH/vd
Enclosure