P8177 Daye Ln r•- - DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTE:Issued in Compliance With'Article II of G.S.Chapter 130a
S nitary Sewage Systems Permit Number
NameQqtp ND 8177
LocationVP/
Subdivision Name Lot No. Sec. or Block No.
Lot Size //f' ,�i,' l-� — House _ Mobile Home —L,�— Business -- Industry
No. Bedrooms _�--.No. Baths "� — No. in Family ^�, _ Public Assembly Other
Garbage Disposal YES ❑ NO p" Specifications for System:
Auto Dish Washer YES NO ❑ ��Cfr"�, Thr'/ , i / ��!
Auto Wash Ma^hine YES 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.
t
f
Improvements permit by —2/i f�—
*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 by
f6 L'r•9G�
Certificate of Completion 79/1r16/ __ 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
Davie County Health Department
Environmental Health Section
P. O. Box 665
Mocksville, NC 27028
1. Application/Permit Req ted By
Mailing Address Home Phone
a70 Business Phone /D � wa
2. Name on Permit if Different than Above
3. Application for: ❑General Evaluation eptic 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 #
❑ Basement/Plumbing
No. of People ❑�Washing
enVNo Plumbing
No. of Bedrooms 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 Water Usage Figures
7. Type of water supply: ublic ❑ Private ❑ Community
8. Property Dimensions '[' 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: > j�
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Aygy ).N
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This is to certify that the information provided is correct to the be y kno Ledge art I understand I am responsible for all charges
Tred from this ap fication.
DATE SIGNATURE
CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY
MUST CHECK ONE: Z�- �. OWN the property. ❑ 2. 1 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:
1 hereby give consent to the authorized representative of the Davie County Health Department to enter upon above described
property located in Davie County and owned by
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)
• DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
NAME N� DATE EVALUATED
ADDRESS PROPERTY SIZE /06 Y'T00
PROPOSED FACIILTY ZW��/� LOCATION OF SITE 0.00'4 --/WZ•
Water Supply: On-Site Well _ Community Public Z_-'
Evaluation By: Auger Boring Pit Cut
FACTORS 1 1 2 3 4
Landscape position 4—
Slope Z 2
HORIZON I DEPTH
Texture group
Consistence
Structure
MineralogX
HORIZON II DEPTH t
Texture groupG—
Consistence
Structure S /C
Mineralogy 1:-t
HORIZON III DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
MineralogX
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE Q C
SITE CLASSIFICATION: D 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 rAay loam, SIL-Silty loam CL-Clay loam SCL-Sandy clay loam
SC-Sandy clay SIC-Silty clay C-Clay
CONSISTENCE
Moist
VFR-Vt!.-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
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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