483 Chiquapin Rd ±7F, '�'��, = DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
4_ *NOTE:Issued`in•Compliance With Article II of G.S.Chapter 130a
y Sanitary Sewage Systems Permit Number
Name +I f'Fs 1° ,r�r !T . <°1�.,'/,,Date N� 6001
Location IL l ' / �I -">' r i 1 f `1 ! !�l .? .j� i d t� ✓�/ °lei
Subdivision Name Lot No. Sec. or Block No.
Lot Size House L-� Mobile Home _ Business -- Speculation
No. Bedrooms No. Baths ? /-`1 No. in Family -
- Garbage Disposal YES ❑ NO EJ--- Specifications for System:
Auto Dish Washer YES NO ❑ d�
Auto Wash Machine YES NO0
❑ ,� ;.X n
Type Water Supply /� 1. --- U4� %="'
*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.
J'
ImprQvements permit by
*Contact a representative of the Davie County Health epartmt for final inspection of this system between 8:30-
9:30 A.M. or 1:00-1:30 P.M. on day of completion. lfelephon Number: 704-634-5985.
Final Installation Diagram: Syrst m Installed by
!r� 0)
r�
J
n
Certificate of Completion L 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.
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
�':f • Davie County Health Department 14
Environmental Health Section
P. O. Box 665
Mocksville, NC 27028
1 . Application/Permit Requested By Jr-SSe, _s /l��Fw cr✓ cT�
Mailing Address 9/-,f 'eaX 30-k /Y/oc,of,f�-//� i✓G o"2>c�lS
Home Phone 3W- N63- a��y5 � Business Phones
2. Name on Permit if Different than Above
3. Property Owner if Different than Above '
4. Application/Permit For: 0 General Evaluation Et S/Tank Installation
5. System to Serve: House Mobile Home l� 0 Business
Industryu Other 0 Unknown
6. If house, mobile home: Subdivision Sec. Lot#
No. of People 3 Dwelling Dimensions c'tS X %o
No. of Bedrooms 3 J+ Basement/Plumbing
No. of Bathrooms a A.- Basement/No Plumbing
0 Washing Machine Dishwasher 0 Garbage Disposai
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
8. Type of water supply: C Public Private 0 Community
9. Property Dimensions on,C_ '4e./e
10. Sewage Disp sal Contractor
11 . Do you anticipate additions/expansions of the facility this system is
intended to serve? 0 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.
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 applicat.ion. . /
Date V Signature
&&I n/ Tv Cll,'.v 2 v.' 1'ci vv c L c f 7'
Directions to Proper y :
A-0 e
171
V
DCHD (10-89) .
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation r
NAME �La d'�-� DATE EVALUATED `� ✓� �
ADDRESS PROPERTY SIZE `tl C
PROPOSED FACIILTY oelg �i LOCATION OF SITE /t'��eA14�
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 ?- Cr
Structure 6ell
Mineralogy /.` l /.- I /' I A I
HORIZON II DEPTH L
Texture group e'* rL
Consistence
Structure i9le le � 46
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 ,
SITE CLASSIFICATION: EVALUATED BY: lorll '
LONG-TERM ACCEPTANCE RATE: 12 OTHER(S) PRESENT:
REMARKS:
LEGEND
Lands Cape 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 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
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