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182 Cornatzer Rd ,. } � � n• „fat =�w,.4�, .i.o-' . 7, -::r T c.. ,+.. „Y f:.. .s DAVIE COUNTY HEALTH DEPARTMENT � r IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION NOT :Issued in Compliance With Article 11 of G.S.Chapter 130a , an itacy,Sewa ehSystems>�/y- /- �,�� � ) Perrmlt�I,,"er Name 'kow ia? �: ` N ( ZS Location Subdivision Name Lot No. Sec. or Block No. Lot Size �lfJ` House — Mobile Home ._ Business __ Speculation No. Bedrooms .No. Baths No. in Family _ Garbage Disposal YES ❑ NO p Specific tions o System: ❑ Auto Dish Washer YES � NO E] � ' Auto Wash Ma shine YESNO ❑ ,�+!�X�,���r � �_�� 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. ;N .r s 4. Improvements permit b *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 b' s 170 Certificate of Completion Dates *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. w DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation NAME �l1�GVC DATE EVALUATED ADDRESS PROPERTY SIZE /�C PROPOSED FACIILTY LOCATION OF SITE Z � Water Supply: On-Site Well 11� Community Public Evaluation By: Auger Boring c/ Pit Cut FACTORS 1 2 3 4 Landscape position .4 Sloe % —' HORIZON I DEPTH --, G~ Texture group S-A L Consistence Structure Mineralogy HORIZON II DEPTH _�'e 3Gv Texture group Consistence Structure 6�h.(� l� •� Mineralogy -7 l ` 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: _At�� LONG-TERM ACCEPTANCE RATE: 4Z 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 DCHD(01-901 MEN ■■■■■■■■■.■.■■■■..■■■■■■■.■■■■■■■■■■■■■■■.■■■■■.■■■■■ ■..00■■■■EI■ ........■■.ii.■■■■■■■■.■N■■■■■■■■...■■NNO■■■■.■■■■M�H■■■M■N■N■■■ ■ .................................................. ............... ........................................................■......... ■■■MM■■■■■EM■■�■■u■.■MMM■M■■M■E■■■■■■■■■■■■■■■■■■■■■■■■■.■■Ee■M■■ ■■■E■M■EEM■■M■�..MM■■MMEMMM■E■EMM■■■■■■■■■■■M■EMM.MEE■.EMe�■■ME■■■ ■■■■■■M■■■■■s■■■■■■.■es■MM■MME■■■MM■■■■M■MM■eM■■■■■■■■■■■■■■■■■mom �iiiiii�iiiiii�iiii�i�iiiii■iI�' iiiiii�iiiiii�iiiiiii�iiiiii� ................■................ ...�.HOME ■�M■MEMEM ■■i■■■■■i1■■■■Ne■■ ■.■■■■.■■■■■■■■■■■■■■■■..■■..■■■■1\■■■►\ MONO■■ .........■■■EEMEE■■.M■■MEM■M■■■■■11■M■.1EME■CR ..i.i■■ii.■.■■■m .......0■■■■N■■■■N■■■■■■■■■■■■■.��■.■■ .... n . ■■ No ■■■M■■!■■■.■E■■■E■EM■■EMMM.■■M■■M11■■■■� ■.=■■E■EM�� ■■■■O■■■■■■ NEON NNONE ■■■■EM■■■■■■■■■■■■■■■■■■■■M■■MM■■■■\MW me SEE 0\■ ■■/ ■■■M �■�■MN mmmmmmmm I■■■■■E■■N■■■■■ ■■■■■■■■■■■■■■■■■■■.■■■■■■■■■.■■ ■■OE. E■■�I .E■M■■E■■■M■EM■E■■ ■■■■■n■■M■MEM■■■■■■■■■■M■MM■■EM■■E■ M■�►'HM MEMO■M■■■■u■■■■■ ■MM■■M■ ■■■■■■MMM■■ ■■■■■■■■■■■■■■■=MN■■►\�■��■■ ■■E■■■M�■MM■■ .■■■M.■iME■C..........................■..■■ \..■ \n■........�.. ■■■■■■■■.■■.■■■■■■■.■■■■■■■■■■■!■■■■H MEMMENOMEMINEM MEMO ■■■\\■■\�■■M ■■OH=■■■ ■■■■■■■■■■.■■■■■■.■■■■■■■■■■■■■N■■■■■■.■ ■■MMMM.1■OM1■H■■■■■■■■■■■ ■■■..■■M■■u■■■■NNNM■■■MM■.M■■M■■!■M■.■N■ ■■u■ ■!■m■N■■■■N■■■■■■ ■■■■■.E■■■M■■■MMM■■■■MM■■MNM■■■■■M■■■■■■ EN■ON�MENI.EME■ ENEEMEN■ MENEEMENNOMMONESSMON ■■■■■■■■■■■■M■■■■■■■M■■■■■■.■■■■■■■■■■■■■■■■M■■N'I■FNM■M■■M■■■■.M■■ NEON ■■■■ ■■■■■■■■■■■■■■■■■■■■.■■t■■OE■■■■.MM■■■■MEM..■/I■■■O■■■■■■E■■■■■ APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT Davie County Health Department Environmental Health Section P. O.Box 665 Mocksville, NC 27028 1. Application/Permit Requested By 2 r /FC-�jYGG �-CSL/ Mailing Address 42 RA�f�,eue& yG 2? � Home Phone �'3�f- f.20 Business Phone 2Z5- — —/4'0 2. Name on Permit if Different than Above Ae� C /zaccJE 3. Application/Permit for: ❑ General Evaluation 2-9eptic Tank Installation 4. System to Serve: Ouse ❑ Mobile Home ❑ Place of Public Assembly ❑ Business ❑ Industry ❑ Other ❑ Unknown 5. If house, mobile home: Subdivision Section Lot # 2-6asemenUPlumbing No. of People — ❑ Basement/No Plumbing No. of Bedrooms . 3 D I�Vashing Machine No. of Bathrooms 2 ishwasher Dwelling Dimensions -2 9oz9 .SF ❑ 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 rivate ❑ Community 8. Property Dimensions /9 A,�—I�ne Sewage Disposal Contractor Y 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes L-IVo 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: w y CA-3 7— J /2j��� ��'P�i✓ z'U�2 ���\ C . S This is to certify that the information provided is correct to t s my knowledge, and I understand I am responsible for all charges incurred from this application. ATE MNATURC CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY Fanddisposal ECK ONE: ❑ 1. I OWN the property. Ci7�'I DO NOT O]tr:eaa:tment ked Box #2, the rest of this form MUST be completed by the owner or a person authorized by th ve consent to the authorized representative of the Davie County Health Department to enter upon cated in Davie County and owned by all testing procedures as necessary to deter d site's suitability fora and absorption s system S 3 _ PATE ATURE DCHD(12-90)