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274 Jack Booe Rd DAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION _ *NOTE:Issued in Compliance With Article II of,.G.S.Chant13 � 9 Sa i ary Sewag Systems,? '�' ' Permit Number Name /J�f'Q/I9G1r, to NO 7152 I/ i—,, / jj/j/ f �j��% 1,(t Azl'l rL� Location _ /-SubK,-//- Subdivision division 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 �j L Speci 'pations,fo�.Sy mem: Auto Dish Washer YES ❑�,..NO U / IiCJ�,a� Auto Wash Ma shine YES p NO ❑ f��f 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. _ L! r" 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 5 L/ Certificate of Completion y 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. - IN APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT Davie County Health Department _ Environmental Health Section f`�t^ p it , EPr) P. O. Box 665 :.� Mocksville, NC 27028 APR , , wwwew4tKw!!!t!! 1. Application/Permit Requested By V-S L Mailing Address � �d k R 7S ZnOC'R 6 U�M9 IV C. -0 7a W Home Phone - �7 7D Business Phone 2. Name on Permit if Different than Above A/D 3. Application/Permit for: ❑ General Evaluation 248eptic Tank Installation 4. System to Serve: ❑ House 2'Mobile Home ❑ Place of Public Assembly ❑ Business ❑ Industry ❑ Other ❑ Unknown 5. If house, mobile home: Subdivision Section Lot # ❑ Basement/Plumbing No. of People 19 ❑ Basement/No Plumbing No. of Bedrooms a "ashing Machine No. of Bathrooms ❑ Dishwasher *Dwelling Dimensions O 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 I�Private ❑ Community 8. Property Dimensions / 4-CJI o �� Sewage Disposal Contractor 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes G-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: X110 I-�-�t L9 b 1 0 0 �0 �CLcY\ -BC) �d d o c�h �e�c k foo �o acl 9 a -b � -s+ 3ri'cL hvuVS oh qou"- r,5 '4- No- be h,n e Ue- houses 12�- 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. 0? , /9�t3 --,� rj DATE SIGNATUR CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY MUST CHECK ONE: ❑ 1. 1 OWN the property. 0-2. 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 thA Davie County Health Department to enter upon above described property located in Davie County and owned by .'// �Gce/,'n to conduct all testing procedures as necessary to determine said site's suitability for a ground absorption sewage treatment and disposal'system. DATE SIGN UREA CHD(12-90) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation NAME < !`e O DATE EVALUATED C5_A1_/4S;�- ADDRESS PROPERTY SIZE AM , l PROPOSED FACIILTY LOCATION OF SITE `& Water Supply: On-Site Well Community Public Evaluation By: Auger Boring !/ Pit Cut FACTORS 1 2 3 4 Landscape position ,Q .L' 2 Slope % -- —� HORIZON I DEPTH Texture group Consistence Structure MineralogX HORIZON II DEPTH 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 RATEI Y I , SITE CLASSIFICATION: Ps- EVALUATED BY: LONG-TERM ACCEPTANCE RATE: " Y 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 ■■■.../........■■.■..■....■....■...■......■■■■■■■■ ■■■■■M■N.■■E■■ mum ME ■■......■....■.....■.■.E.M.M..MM.EN..EE■M■■...■..■.■. .■.■■/.MEN MMMMMMMMMMM mom NONE mommommommommomom EMMEMMOM ■■.■■■■■■■■■..■■■MDMM■MMMMMMMM■E:CM■MEM■MM■MM. .■■■■■■■....■.■■■. .................nN■■■■■■■M■■O■O.■.■■■■■■■■MMCCM■M■MME■N■.■■■■■■■ .......................■■■■■■■■■■■■■EE.■E■■.■■■E■■■M■....�....... ■■■■■■■..............................■.............. .... ■■EM■N■ ■■■■■■■■M■■.■M■MM■■■■■E■EiMi■m9a ---=MEN ■e■■■■■M.MNC■■■E■E■■■E■■■ ■■■■■■■■■■■ENE■■M■■■M■■■NI■MME■■NCM■;MEN M ■MINES.■■MMEMO ENM■■■■■■M■ ■■■■■■■■■■■■■■■■■■■■■■■■NIONOM■■■■■■OMEN■■■■■■■■■■■■NOON■■■■■■■■■■■ ■■■■■■ ■■■■■■�M■NEEN'MM■MMEN�■■■■■■�■■■■■■ ■NONE■�■■■■■■, MEME■M ■■.■■■ ■MENEM M■■■■■ ' ■■M■■. ■■EME. ■ ■■M■ ./■■■■ ■■■■■■■■.■ MEMO■ONO■■mom■ MNC■■■■M■M■■M■■■■ ■■■■■.■■.■..■e■■■■■■.■■■.tMMMMMME.........................�.■■■.■■. ■■..■■N■.■..■..■■MEMEMMENIMEME■E■E■■■■MM.■IMMEME MMM■■■N nNEMON .■.■..■■ MEMO.■M■■EN.■NEmom■ENEMM!!!�-- ___.. ■■■.■. .�..■.■...■MMEMO .■E■E■■■E■M■■■■■■■■M■■■■■■■■E■E■E■M■■■ ■ ■ .Emom Ee.■.NONE ■E■■.■■■■.E■■■NE.....■ ■E.■EME...EM..C:C■E■ ■ .. ■ E■ ME■■■■■ NONE.■■.■.■■■■■MME■EM■MCNEMMEMEMISEE�MN■.�n� IN MEN ONES■■■...■..■.M.EMEME■E.....■.. 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