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627 Jack Booe Rd (2) DAVIE COUNTY HEALTH DEPARTMENT t -IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION �ko 'NOTE:Issued in Compliance With Article I I of G.S.Chapter 130a Sanitary Sewage Systems Permit Number Name��1 12 LZ 1�1L�.� � ' ^� f�-- Date � 1�5~ ND 7 8 7 4 Locationj�y - /L.�� ,O619 _4ZLj Subdivision Name Lot No. Sec. or Block No. Lot Size -_---- House — � Mobile Home ---- Business -- Industry No. Bedrooms --?' _.No. Baths No. in Family Z Public Assembly Other Garbage Disposal YES NO ❑ Specifipations for System: Auto Dish Washer YES NO ❑ ,-; Auto Wash.Ma^hive YES NO ❑ -Jia Type Water Supply 00 jk '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. out 11 �SG 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., 1:00-1:30 P.M. or 4:30-5:00 P.M. on day of completion.Telephone Number: 704-6345985: Y160 Final Installation Diagram: System Installed by e4,, ' lv� �0 ry'a' 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 PER r .. Davie County Health Department tc;. C�:S i� E ' j Environmental Health Section P. 0. Box 665 FEB 15 1995 Mocksville, NC 27028 1. Application/Permit Requested By Mailing Address Z 0,, /3o,r,1Q/l/ Home Phone 9'/0- 7GO-OD 7L IV/ti�oH- JT l� , IVC Z71L4 Business Phone Z /� 17-f--7» 2. Name on Permit if Different than Above 111114 3. Application for: 0 General Evaluation WSeptic Tank Installation Permit 4. System to Serve: E3- House ❑ Mobile Home ❑ Place of Public Assembly ❑ Business ❑ Industry ❑ Other ❑ Unknown 5. If-house, mobile home: Subdivision � H.v%�l"3 f J" Section Lot # E- 1�asement/Plumbing No. of People �" " _ ❑ Basement/No Plumbing 9 No. of Bedrooms P Washing Machine No. of Bathrooms S Q Dishwasher Dwelling Dimensions 41 B"Garbage Disposal 6. If business, industry, place of public assem ly, other:. Specify type ZA 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 ❑ Private ❑ Community 8. Property Dimensions vvte✓ Sewage Disposal Contractor 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ 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. Directions to Property: p Jorc% Booe AVC1, rPkf h. ✓licha�ol�9`za�n/voG ele- a bouR- eOo lft o L ti O C Ire- 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. z /-sgs �� - - o .. DATE SlGfXTURE CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY MUST CHECK ONE: �. I OWN the property. ❑ 2. I 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 If disposal system. DATE SIGNATURE DCHD(1193) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section ` Soil/Site Evaluation NAME 4 DATE EVALUATED ADDRESS n/ PROPERTY SIZE 5S PROPOSED FACIILTY /7�/ LOCATION OF SITE 211 C/Af Water Supply: On-Site Well rl _ Community Public Evaluation By: Auger Boring (/ Pit Cut FACTORS 1 1 2 3 4 Landscape position Slope % HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH C Texture groupC C Consistence Structure ii 4 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 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 Aay loam, SIL-Silty loam CL-Clay loam SCL-Sandy clay loam SC-Sandy clay SIC-Silty clay C-Clay CONSISTENCE Moist VFR-V----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 -3C--Single grain M-Massive CR-Crumb GR-Granular ABK-Angular blocky SBK-Subangular blocky PL-Platy PR-Prismatic Mineralocty 1:1, 2:1, Mixed Notes Iforizon 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 ■■■■■■■■■■■._■.■■■■■■■■.■■■..■■■■■■■.■■■■■..■...■ ■....■..... ■MOM ■.■■■■..■■■.■■■■E.■.MM■EMSE■SEn.■.E■...■■..■�.■■.■.■...■.....■.■■■ ................................................... ............. 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