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136 Cherry Hill Rd ;.* i .. o *+ ':..� ,W,`K DAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION •NOTE:Issued in Compliance With Article II of G.S.-Chapter 130a Sanitary Sewage Systems Permit Number NameND Date LA �,V - '�� '71 9 U Location 1' ' t..c \ t�..��-.f...?,J� `., >> ��`�', \�`:� ' �'� n...S'*•. , \\, �. '� I v cl�, Subdivision Name Lot No. Sec. or Block No. '�.,s._r..n.r� Lot Size �—�--- House _ Mobile Home Business __ Industry No. Bedrooms ''_.No. Baths -- No. in Family *"``F' V Public Assembly Other Garbage Disposal YES Q NO [y Specifications for System: Auto Dish Washer YES p NO Cg/ Auto Wash Ma^hine YES [g NO ❑ 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 ATTENTION: YOUR SEPTIC SYSTEM CONTRACTOR MUST SEE THIS PERMIT/LAYOUT BEFORE INSTALLING THIS SYSTEM. 4-� Improvements permit by \_``Lt, ,',y,� �\�� '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: 704-634.599-85. Final Installation Diagram: System Installed by 136 Id"tN 5 B _a �J B Q Certificate of Completion \ - ` Date - J> _ 'The signing of this certificate shall indicate that the system descri ed above has been installed in compliance with the standards set forth in the above regulation, but shall in.NO way be aken as a guarantee that the system will function satisfactorily for any given period of time. ' APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMI Davie County Health Department Environmental Health Section P. O. Box 665 Vr -7 IN Mocksville, NC 27028 T HEAL 1. Application/Permit Requested By UVt,a ("l IM +J + Mailing Address 1� �N`�L �k k L k 2sa\d Home Phon 0 Q us Business Phone 2. Name on Permit if Different than Above 3. Application for: a General Evaluation 6319e-ptic Tank Installation Permit L 4. 7usiBusiness to Serve: ❑ House ❑ Mobile Home ❑ Place of Public Assembly ❑ Industry ❑ Other ❑ Unknown 1 2 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 ❑ Garbage Disposal 6. If business, industry, place of public assembly, other: Specify type No. of People Served c- No:of Sinks 0- No. of Commodes 11 No. of Urinals — No. of Lavatories _ I No. of Water Coolers No. of Showers Water Usage Figures �a Q�S• -V 7. Type of water supply: Public ❑ Private ❑ Community 8. Property Dimensions I s Sewage Disposal Contractor 9. Do you anticipate additions/exp sion of the facility this sytem is intended to serve? ❑ Yes D-fq-o� 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: haJ4 410 1 <)0d Z5 r - 72 This is to certify that the information provided is correct to the best of m kn d I and stand I a responsible for all charges incurred from this a p'catioOfEd-0 21 AA 3 qs /DATLf CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY MUST CHECK ONE: �1LU. I OWN the property. El2. 11 Q 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 County Heal a int to enter upon above described property located in Davie County and owned by to conduct all testing procedures as necessary to determine s ' for a g o nd absorption sewage treatment and disposal system. 3h i5ATE IGNATURE WHO(1/93) + DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil\/Site Evaluation q NAME ��Q A4. DATE EVALUATED ADDRESS `� PROPERTY SIZE \ C PROPOSED FACIILTY ) � � �-'''Q^'] LOCATION OF SITE Water Supply: On-Site Well _ Community Public Evaluation Byl�t� Auger Boring V1 Pit Cut FACTORS 1 2 3 4 Landscape position s S l o e Z c6 , ';c� $-1116 HORIZON I DEPTH it Texture group F2� C,tL Consistence Structure .MineralogyHORIZON II DEPTH 2 Texture group C Consistence FYI Structure S Mineralogy '.) HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON r SAPROLITE — CLASSIFICATION LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: EVALUATED BY: LONG-TERM ACCEPTANCE RATE: OTHER(S) PRESENT: REMARKS: \\, �1. 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 ;lay loam, SIL-Silty loam CL-Clay loam SCL-Sandy clay loam SC-Sandy clay SIC-Silty clay C-Clay CONSISTENCE Moist VFR-V? .-y 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 - 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 ■■■■■.■.■■■■..■■■■■■■■■■■■■..■■..■■■■■■■■■■■■■■■■.■■■■■■■■ ■EM■■■■ ■.■■■■■■..■■■■.■..■■■...■.■ .■■..■.■■■.■■■■■■■■:NOON:■■■■:■■■■■■■■ ■■■■■■.■.■.■■■.■.■■E■■E■e■.■■■■■■■!■■■■■ ■■■ MMMEMMEMEMEMMEMS No ............■.....................:.....■■■■OU■.■EEEE■■..:■■ ■■MEMM OEM :. ..................■■■■■■Ee■■■■E■■■■■■■■EEE■■■EHE■ . ........ ... 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