P6967 Gladstone Estates I/X.0
DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTE:Issued in Compliance With Article 11 of G.S.Chapter 130a
Sanitary Sewage Systems Permit Number
-F Date N2
6967
Name
Al
X2
Locatio
Subdivision Name Lot No. Sec. or Block No.
Lot Size House Mobile Home L< Business'--- Speculation
No. Bedrooms No. Baths No. in Family 42
Garbage Disposal YES E:] NO 0'
Auto Dish Washer YES NO
Specifications for System:
E]
Auto Wash Ma shine YES NO
Type Water Supply 41
*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.
Improvements permit by
*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
Certificate of Completion 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.
T
ti DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation > J
NAME / DATE EVALUATED
ADDRESS )� PROPERTY SIZE
PROPOSED FACIILTY LOCATION OF SITE (-,/22"7f
Water Supply: On-Site Well Community Public
Evaluation By: Auger Boring L'111 Pit Cut
FACTORS 1 2 3 4
Landscape positionSlope %
HORIZON I DEPTH
Texture group
Consistence
Structure
MineralogX
HORIZON II DEPTH 11 f �t 'zit
Texture group
Consistence
Structure
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 y�
SITE CLASSIFICATION: / -� 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 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
■■■■■■■■■■■■■■■■■■■■.■O■■.■■■■■■■■■//■.■...■..■■■■■■■■■..■...■tit■
iiiiiiiiiiiiiiiiiiiiiiiiiii®iiiiiiiiiiiii�iiiiiiiiiii■iiiiiiiiiiiii
■■■■■.■.■■.■......■......■...........■■■■■■■■.e■.■■■.■■■.■...■I■■■
■■ss■■■■■■■■■■■■■■■■n■■■■■■■■....■■■■■■■■n■■..■■■■■■■■■■■■■■■■■■.■
■.■■........■■..■..■■.■■epee====:::■■....i�......■■..........■..■.■
■.............■■........ren■......n■■.....i�■......n■....■■....■..■■
iiiiii�iiiiii�iiiiiii�■/■■/■ ■/■■■/ �■■/■■/ ■■///■�■■■■■■
moon.■ .■■■■■ ■■■■■■ .■■... ■....■
■■■...■■■....■■■■■■■■...inn...■■■..■■■■..■■■■■■■■.■■■■■.■■■■■■■■■■■
............................................................. mono
■■■...■■■...■■■■■■■..■■■.■.■..■n■■..■■■■■■■■■■ ■■ ■■■■■■■ ■mono■ ■
■..■■■■■..■■■.■■■■■....■■■..■...�..■■n.■■■■■..■ ■■■■■■.■■■■■■..n■
■■■■■■■ ONE 00
........................................... .....................
................................ ............................■.■■
..................................................................
..................................................................
..................................................................
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PE_____
��,r . rQp�®
Davie County Health Department 1.- ItV
Environmental Health Section DEC a � �
P. 0. Box 665
Mockaville, NC 27028
1 . Application/Permit Requested By 96t? ev- SAna
Mailing Address , , G ti b L a l - NG 2 7 o I
Home Phone /d T ' < 7Business Phones
2. Name on Permit if Different than Above Jl
3. Property Owner if Different than Above c[A re-t4c e- 14 Q kJ
4. Application/Permit For: General Evaluation a,.S-/Tank Installation
5. System to Serve: :House bile Home (] Business
-] ::Industry u Other 0 �Unknown
6. If house, mobile Thome: Subdivision Sec.7�T, Lot#1
No. of People Dwelling Dimensions
No. of Bedrooms Basement/Plumbing
No. of Bathrooms ?/' Basement/No Plumbing
0 Washing Machine eDishwasher 0 Garbage Disposal
7. If b ZZ
r:lS
othehe r: pacify type
No. of People Served Z No. of Sinks
No. of Commodes No. of Urinals
No. of Lavatories No. of Water Coolers A141 e,
No. of Showers
S. Type of water supply: C Public 94-Ir ivate (a Community
9. Property Dimensions
10. Sewage Disposal Contractor
11 . Do you anticipate additions/expansions of the facility this system 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.
This is to certify that the information provided is correct to trice
best of my knowledge, and I understand I am responsible for all
charges incurred from this applicat o
/.2 I/r ?2—
Date tignXture
Directions to Property :
��S�ov� e. �6� 2►- �e.�are-- �ev,c� fie �,�t o
DCHD (10-89)