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459 Cedar Creek Rd (2) DAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION 'NOTE:Issued in Compliance With Article II of G.S.Chapter 130a ) `j ,�� U Sanitary Sewage Systems Cil��;� ��c��'�� /)1� A ' "w"� �� Permit Number Name. -= ,- ��'C o_r�� --�--Yate _ N_ 8149 Location Subdivision Name `R Lot No. Sec. or Block No. Lot Size ` L — House _�'� Mobile Home —_—_ Business -- Industry \ n i No. Bedrooms No. Baths _—L— No. in Family — Public Assembly Other Garbage Disposal YES p N0 [H° Specifications for System: Auto Dish Washer YESNO Auto Wash Ma':hine YES l� NO Type Water Supply � :N *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 ATTENTION: YOUR SEPTIC SYSTEM CONTRACTOR MUST SEE THIS PERMIT/LAYOUT BEFORE INSTALLING THIS SYSTEM. Improvements per by = ~. –, _'� i . *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: System Installed byr\�) ion Certificate of Completion Date 'The signing of this certificate shalFindicate 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. ATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT Davie County Health Department �- 4Reques Environmental Health Section L ,7 AUG - 7 P. O. Box 665 /�/ Mocksville, NC 27028 1. Application/Permit _/�o/�� anA) `'I�z 1i' �h —��/�rnZ Mailing Address A*7r-�53 6A 261 Home Phone Business Phone Oltl— f--7g.5 "100-5 2. Name on Permit if Different than Above 3. Application for: ❑General Evaluation grSeptic Tank Installation Permit 4. System to Serve: House ❑ Mobile Home ❑ Place of Public Assembly ❑ Business ❑ Industry ❑ Other ❑ Unknown 5. If house, mobile home: Subdivision Section Lot # goo ❑ Basement/Plumbing No. of People�_ ❑ Basement/No Plumbing No. of Bedrooms Washing Machine No. of Bathrooms ' ❑ Dishwasher Dwelling Dimensions ❑ 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 WVp-rsivate Uage Figures 7. Type of water supply: ❑ Public ❑ Community 8. Property Dimensions 3/ a C aJ 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: 1 � N. /��g�JAV� �v /�� fj T Gz/J C,°d'!�-� C/Z-e e�! O ,,5►-,6Od/ �/� /'��CS r i�/�//�I �Ov �/.v e,cT '/w/-Pve s A)&7' ROA AW,10 /r (JA)7.4-L This is to certify that the information provided is correct to the best of my knowledge, and I understand I am sponsible for all charges incurred from this application. " DATE SIGNATURE CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY MUST CHECK ONE: ❑ 1. I WN the property. I DO NOT OWN the property. If you checked Box #2, the rest of this form MUST be completed by the owner or a person authorized by the owner: I hereby give consent to the authorized representative of the Davie CountyHealth Department to enter upon above described property located in Davie County and owned by 4010 Q� and to conduct all testing procedures as necessary to determine said site's suitability for a ground absorption sewage treatment and disposal system. DATE SIGNATURE DCHD(1/93) NORAEATON ROUTE 5 BOX 74 MOCKSVE.LE, 27028 998-3709 I40W to Farmington exit, turn right, • •umiles pass Pudding (thisRidge Road, travel about 2/3 miles, make a right on Cedar Creek Road, drive about 1112 mile until you get into a deep curve, make an immediate left o • that is not easily seen from • drive • • in wooded area, house is green white. It bi the only house. on road. hit ail' ,'• �r .�.e�.•y �t f` •' ':: `�A�r,�.^Z'�!C► ?��,-� •� ..!Mr;••rte.: _ .. FORSYTH BUILDERS 9 WAUGHTOWN WINSTON-SALEM, 1 i DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation NAME 'v A 1 DATE EVALUATED 9 �' 7� ADDRESS S '1 PROPERTY SIZE 3 PROPOSED FACIILTY �`�a a'(\ �1� NVUSQ LOCATION OF SITE i K+ Water Supply: On-Site Well Community Public Evaluation By:C�_L Auger Boring 1� Pit Cut FACTORS 1 2 3 4 Landscape position s j Sloe X -IS-° 'IS 7-130 8-1 HORIZON I DEPTH Texture group Consistence T -1 Structure C Mineralogy HORIZON II DEPTH j4:111 12 Texture group Consistence Y__IT �= Structure Q M 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: �` LONG-TERM ACCEPTANCE RAT : OTHER(S) PRESENT: �ty 010- REMARKS: �`•� _ � a 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 3C-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 - $(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 ■■■■fC�■11..■■■■11■■■! l■■I■■■■..■.■. ■■I■■11■.■■�■■■■■.■■■■■■■■■■■■ ■■■ ■■.■C�■■■■■■r11�1■■■!i■.Iw.■■.■■■■■ ■\I■■W■■■■ ■■■.■■■■■■■...■..■■■■■ ■.■■6�■■■■..i�!I�■■■ll/l.■Irltr/■■■..■■..■■ala■■■.■■..■■■■■■■t�■■■■■.■■■■■� ■iii:CC�G�i!■■■.'C.a:.::��71■■■■■■■.■■■■/1■■■■■1\■■■■■■■■■■■■■■■e■■■■■■■■■ ■■■■■■■■■1�■■■■,■■■■.Incgal■■...■.■.■�r�.■.■i►�■■■.■■■■■.■■■■■■■■■■■■■■■ ■■■■�`/■�I■■■■■■■■■■■■■.■■■■■■■■■//■■■■■■/i■■■■It■■■7.■pill\�.■■■■fl.■■■ iiiiiiii■�■liiiiii■■iiiiii■�=■iiiiinUiiEM iiME®ii' IR=iii �.�iiiiFAiiMEMEMEMEMEMMEM ■�ji ..........iri�i====...��....... ■r■MO■■■■■ eC.C■e ■■.e■■I iiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiii"i=ii'■iil�uiii�l�i�iiii■siiiiiiii■ ■■■■■■■■■■■■■■■■■■■■■■■■■e\1■.■■.�I1■■■■N■0■■ ■■■■■■■■■■.■■■■■■ ■■■■.■■ MEN u■■■■u■■■n■■ :�::MMEMMMIKEME ■■■■■■■■■■...■■.■..■....■It.■■■■N■.I\.■i.. ■i■■■u■■.■i.■■.■■■i■■■■ ■■.■■■■■■■■■■.■■■■.■■■■■■■■■■ ■■■■■��■■■■.■■.■■■■■■■■■■■■■u■■■■■■■ ■.■■■■■■.■■.■■■■■■■■�i.■.■I■.■l ..y■�i■■.e.■.■■■■■■■■■■■■■..■■■■.■.■ ■■■._...■■■■■..■■■■.■■.■■■■■■■■■ ■■I�■■.■■■..■■■■■.■■■.■■■■■u■■■■