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125 Imperial Ln DAVIE COUNTY HEALTH DEPARTMENT a�.y k IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION 'NOTE:Issued in Compliance With Article 11 of G.S.Chapter 130a Sanitary§ewage�Systems Permit Number Name �....`..a� � s.��r Date ��\ - �� N° 7468 Location N4 Subdivision Name Lot No. ,! Sec. or Block No. Lot Size House Mobile Home Business Business Industry No. Bedrooms No. Baths _-J-- No. in Family_at___— Public Assembly Other Garbage Disposal YES C] NO p� Specifications for System: Auto Dish Washer YES ❑ NO Q' p o d� ~�s Auto Wash Ma^hine YES Q' NO ❑ , ► h Type Water Supply -S— �- *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. R<` Q 4 Qc y, Improvements permit tj "Contact a representative of the Davie County,Health Department forfinal 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. b Installed stem -' Final Installation Diagram: System �Y — Iv Certificate of Completion ` Date `- -3 4 '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 EC ETV l!� Davie County Health Department Environmental Health Section iJAR - 91994 P. O. Box 665 Mocksville, NC 27028 1. Application/Permit Requested By PObee-1 Ot a q & e-ul h Mailing Address l0 . ADy 2 :5:24 I Home Phone � -�qV �p �D Sr�//fie, �y • t✓. Business Phone 6 3y-327,5 2. Name on Permit if Different than Above 3. Application for: ❑General Evaluation U"Septic Tank Installation Permit 4. System to Serve: ❑ House EKMobile Home ❑ Place of Public Assembly ❑ Business ❑ Industry ❑ Other ❑ Unknown 5. If house, mobile home: Subdivision Section Lot# ❑ Basement/Plumbing No. of People ❑ Basement/No Plumbing No. of Bedrooms r7. PWashing 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 Watters Usage Figures 7. Type of water supply: ❑ Public 2 0rivate IiJI-f""' a4 Oh"✓'�'❑ Community 8. Property Dimensions 1 (10P-r Sewage Disposal Contractor 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes CNo 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: .H ley CA l..a5 +,o :�U1 ��t��ca� �'ul road 6 ;d e 4-had 5a.y::5 .Tnioer/Ld kar)e. a n . The 0)(D 61 he hon-7c +J,)o J, 1s 71 e. eoloP- ; 6 blues Y whl /e This is to certify that the information provided is correct to the best of my knowledge, and I understand I am responsible for all charges incurred from this application � —� DATEf� SIGNATURE CONSENT FOR SITE EVALUATION!Q BE DONE CSN ABOVE DESCRIBE PROPERTY MUST CHECK ONE: ❑ 1. 1 OWN the property. — 2"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: I 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 syste p � A-� DATE SIGNATURE DCHD(1193) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation h NAME D�D�Z� ` Ay C� RDATE EVALUATED ADDRESS S a,tc. PROPERTY SIZE PROPOSEDFACIILTY `M" LOCATION OF SITE Water Supply: On-Site Well Community Public Evaluation By: L- Auger Boring Pit Cut FACTORS 1 2 3 4 Landscape position -S s• Sloe % - u - Z o -I r ..v HORIZON I DEPTH L ' Texture group L_ I— e�- Consistence _T_ Structure lz R Mineralogy T • I ; ' HORIZON II DEPTH 4 1-1 Texture grouC Consistence p Z z - _ Structure �R 17 Mineralogy HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS S� RESTRICTIVE HORIZON — SAPROLITE — — -- — CLASSIFICATION LONG-TERM ACCEPTANCE RATE`S SITE CLASSIFICATION: v ' EVALUATED BY: LONG-TERM CCEPTANCE RATE: OTHER(S) PRESET: a f �-c�- REMARKS: ► \ C.. � *�� .I 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-Film 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/fU DCHD(01-901 ■■.■.....■...■■...■.■■.....■■■■■E■....■./..■.../MEMO../.■...■e..■ ■.■■.......■...■..■....■■■■..E■■E.■tE.../....../.e.■■.....■■..■■■■ .............................................. ........ .......... ■■.■...■.■a.......■..■■....■..........■.. /■■._■■■ ■■■. monsoonMINN ■■■■■■.■.■■■..■■..■...■.■..■....■■■.■.■■�■■■■■■■■�■■■■■■■■■.■ ■■ MEN ■■M.eO.//.■.■■.■..■i.■E■O■■.■■■■ ■■.M■./.Ila ■■C/~.:. .....M/.■..■ e■. 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