1189 Jericho Church Rd (3) -,,: yi,�-aF' ",ra'.�'°*� -t.,.•.:ar'v.^-,t,,� ra>... .r >, r ... -.
DAVIE COUNTY HEALTH DEPARTMENT _„_
IMPROVEMENTS PERMIT AND CERTIFICATE--OF COMPLETION
*NOTE:Issued in Compliance With Article 11 of G.S.Chapter 130a
nitary Sewage Systems Permit Numbero
Name Date �i'w - `�'f'. N2 1
Locatio
Subdivision Name Lot No. Sec. or Block No.
Lot Size ��,rHouse Mobile Home Business Industry
No. Bedrooms No. Baths No. in Family Public Assembly Other
Garbage Disposal YES p NO p' Specifications for System:
Auto Dish Washer YES p NO
Auto Wash Ma^hine YES El NO (Er-
Type Water Supply /76
*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 — A412,Z
*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:704-634-5985.
Final Installation Diagram: System Installed by _
pgk
Certificate of Completion _� 1Date
*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 as a guarantee that the system will function
satisfactorily for any given period of time.
' APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
i r Davie County Health Department /
Environmental Health Section e �
P. O. Box 665
,.. . .. . . ... .. .. . . a
Mocksville, NC 27028 14� _/�_�
e
1. Application/Permit Requested.Byu-
Mailing Address t'� ,(? 1 J7 Home Phon ?O 3q-(j.-
� daP�,�7� IJ afl a Business Phone 3491-=.(e
2. Name on Permit if Different than Above
3. Application for: O General Evaluation doSeptic Tank Installation Permit.
4. System to Serve: la House ❑ Mobile Home ❑ Place of Public Assembly
❑ Business ❑ Industry ❑ Other ❑ Unknown
5. If house, mobile home: Subdivision Section Lot #
❑ Basement/Plumbing
I No.of People O Basement/No Plumbing
No. of Bedrooms_�� O'Washing 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 Water Usage Figures
7. Type of water supply: 0ublic ❑ Private ❑ Community
8. Property Dimensions Sewage Disposal Contractor
9. Do you anticipate additions/expansion of the facility this sytem 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.
Directions to Property:
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This is to certify that the information provided is correct to the b t of my knowledge, and I understand I am responsible for all charges
Incurred from this applicati n.
DATE SIGNATURE
CONSENT FOR SITE EVALUATION TO EE DONE ON ABOVE DESCRIBED PROPERTY
MUST CHECK ONE: ❑ 1. 1 OWN the property. ❑ 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 system.
DATE SIGNATURE
DCHD(1h)
•l "- – DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
NAME I GL�(f/ DATE EVALUATED
-. .PROPERTY SIZE fIC
ADDRESS
�`�'CS{ LOCATION OF SITE Jl�/��%
PROPOSED,FACIII,TY __�
Water.Supply:, On-Site Well Community Public
Evaluation By: -Auger Boring ✓ Pit Cut
FACTORS 1 2 3 —77 4
Landscape positionSlope
HORIZON I DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH G7 61
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
SITE CLASSIFICATION: EVALUATED BY: T
LONG-TERM ACCEPTANCE RATE: OTHER(S) PRESENT:
REMARKS:
;. ;. LEGEND
Landscaoe 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 friableFR-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
Mineraloay
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