1184 Hwy 801S Al �_ w
DAVIE COUNTY HEALTH DEPARTMENT "N
;IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION W W
*NOTE:Issued in Compliance With Article II of G.S.Chapter 130a 3-�)
"1411-e O 6T
an to Swya a Systems> ' ' r Permit �1 er�d"�
�f J/ ate /� '
Name -
Location —
Subdivision Name Lot No. Sec. or Block No.
Lot Size House Mobile Home _ Business Speculation
No. Bedrooms No. Baths No. in Family _
Garbage Disposal YES ❑ NO Il�ry
Specifications fof System:
Auto Dish Washer YES ❑ NO /pQ��;'61
Auto Wash Ma shine /,YES p NO ❑ / CC/%
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 a change.
SO '
Improvements permit by -- —
representative of the Davie Count Health Dept{t ent for final inspection of this system between 8:30-
Contact a p Y tm
9:30 A.M. or 1:00-1:30 P.M. on day of completion. Telep 'r a Number 704-634-5985.
Final Installation Diagram: Syst m Installed by
v
h
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.
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PE #M-u
Davie County Health Department
Environmental Health Section
P. 0. Box 665 OCT
Mocksville, NC 27028
-JJ
1. Application/Permit Requested By,
Mailing Address -12aX 111,K-
Home Phone Business Phone
2. Name on Permit if Different than Above
3. Application/Permit for: 0 General Evaluation (D-teptic Tank Installation
4. System to Serve: D House 0 Mobile Home 0 Place of Public Assembly
El Business El Industry 0 Other 0 Unknown
5. If house, mobile home: Subdivision Section- Lot#
0 Basement/Plumbing
No. of People El Basement/No Plumbing
No. of Bedrooms El Washing Machine
No. of Bathrooms El Dishwasher
Dwelling Dimensions 0 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 Z Water Usage Figures
0 0
7. Type of water supply: El Public ar'Private Community
8. Property Dimensions Sewage Disposal Contractor 'at'�
a,
9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? D Yes 2'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.
Wtyl
Directions to Prope
41,
This is to certify that the information provided is corre m responsible for all charges
incurred from this application.
DATE
CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY
M MUST CHECK ONE: 09,1' I OWN the property. 0 2. 1 DO NOTUWthe property.
UST C
c
If you checked Box#2, the rest of this form MUS be completed by the owner or a person authorized by the owner:
if you c
y gi
I hereby give consent to the authorized representative of the Davie County Health Department to enter upon above described
I r
p r p y 10
roperly located in Davie County and owned by
p 0 rt
tco uct
to conduct all testing procedures as necessary to determine sai�KsW/guijabilitv,4or-a groupnER) tion sewage treatment
ispos
Faond disposal system.
10,
DATE 9IGNAT?nE
DCHD(12-90)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental'Health Section
� Soil/Site'Evaluation
NAME- r5/I 2'Y�� DATE EVALUATED
ADDRESS PROPERTY SIZE
PROPOSED FACIILTY LOCATION OF SITE
Water Supply: On-Site Well L"-� Community Public
Evaluation By: Auger Boring Pit Cut
FACTORS 1 2 3 4
Landscape position L L ,�
Sloe % -
HORIZON I DEPTH
Texture group /
Consistence
Structure
Mineralogy
HORIZON II DEPTH
Texture groupG
Consistence
Structure
Mineralogy /. /, Y /.
HORIZON III DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE 71
CLASSIFICATION S S
LONG-TERM ACCEPTANCE RATEI y I
`J
SITE CLASSIFICATION: / EVALUATED BY• /lG /Z
LONG-TERM ACCEPTANCE RATE: �1 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
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