The URL can be used to link to this page

219 Jesse King Rd 1,40 DAVIE COUNTY HEALTH DEPARTMENT Gt� oa IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION N6TE:Issued in Compliance With Article I I of G.S.Chapter 130a Sanitary Sewage S�stt s 7 q Permit Number Name�A�+ �� `cam A ri Q 5 _ Date L!1 3 " 14 N27650 Location � ,_ `��C\y V,N c N . . Uo to Subdivision Name '�'''� Lot No. Sec. or Block No. Lot Size o 2 n House Mobile Home — Business -- Industry No. Bedrooms No. Baths — �-- No. in Family — Public Assembly Other Garbage Disposal YES ❑ NO E� - Specifications, for System:,.,, Auto Dish Washer ., YES ❑ NO [g� / 0 0 Q o q `S ' - b Auto Wash Ma^hine YES N6-[j, Type Water Supply *This permit Void if sewage system described belo is notinstalled within 5 years from date of issue. r This permit is subject to revocation if site plans or he intended use change. j+ �, . . Improvements permit by —_ *Contact a representative of the Davi Coun 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 ay of co pletion.Telephone Number:704-634-5985. Final Installation Diagram: System Installed by 1J i� Certificate of Completion �!- Date -�% *The signing of this certificate shall indicate that th� 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 PERMIT f �Z ' Davie County Health Department IN Environmental Health Section P. O. Box 665 FEC �t� � Mocksville, NC 27028 71994 1. Application/Permit Requested By aU S . ........ _ Mailing Address n vl0 f>,N Home Phone 3 !kesuati ,1' Business Phone 2. Name on Permit if Different than Above 3. Application for: ❑General Evaluation Ql Septic Tank Installation Permit 4. System to Serve: ❑ House GL Wile 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 ��- O Washing Machine No. of Bathrooms ❑ Dishwasher Dwelling Dimensions ?d ❑ 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 2-Private ❑ Community 8. Property Dimensions '100 cQ`^ Sewage Disposal Contractor 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes t leo 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. rl S} y ,� �� CS.,�-, ��. ,.. �.,s p4, Directions tT4operty: � "1 SAO l �ro -An , I��- !28 l►� N 6 y g»k 11 U 11 oa J 5 o 3 rw �4 e� A JV Ii i h (�4 y l t:�I b\A- oma• 5-es S i e k i htl /?o o c), Cl- 2 f vli kP 011-f4 L -��1' See,. mel )\ 8 o x %.,,I - L-e T r-i-^%y Is don j wc,,y . 111 1 1►"C�,� 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. 14 t) - - F) DATE SIGNAT RE CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY MUST CHECK ONE: D-I-TOWN 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. ::2Z?6 F/ 13ATP SIGNATURE DCHD(1/93) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation (} NAME AN A'S DATE EVALUATED I 1 J ADDRESS A rc� 's PROPERTY SIZES PROPOSED FACIILTY NA\- �' A LOCATION OF SITE -nom_ R Water Supply: On-Site Well Community Public Evaluation By: Auger Boring Pit Cut 1/ FACTORS 1 2 3 4 Landscape position S -S• S Slope Z 0-CS° O'Cs° Q- o �- HORIZON I DEPTH `` b`' ti Il Texture group C (, Consistence Structure I Mineralogy HORIZON II DEPTH N' `' ` 1t' Texture group Consistence !� Structure Mineralogy HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS Ss _S_ �s RESTRICTIVE HORIZON — — SAPROLITE _ — — CLASSIFICATION 7S. LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: Q S EVALUATED BY: LANG-TERM ACCEPTANCE RATE: \'AOTHER(S) PRESENT: {ay` a � n �-w1 �� a ' � "'A!-h REMARKS: O 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 (:lay 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 iiiiiiiiiiiiiiiiii�■iiiii�i�■iii!�iiiiiiiii�iiiiiiiii■iiiiiii'i■=iii ..................................■............... ......■........ iiiiiiiiiiiiiiiiiiiiiiiiii■iieiiiiiiiiiiiiiiii'iiiii.�iiiiiiiiiii ■■■■■.■■■■■■■■■■.■■■■■■■■■■■■■■■ ■■■■■■.■.■■..■■.■■■.■■..■■■■.■■■ iiiiiiiiiiiiiiiiiiiiiiiiiiiiiiii=iiiiiii!'�iiiiiiiiiii�iiiii■.iiiiiii MEMNOi ■ iiii■OOMEN MiiiiiiMENEM � ......................................... ....... n.■.■■C■■■■..■■ .........................................E....... ■M...■■..■.■■.■■ ...............■......................S:i■C:=:.' C.I:I::I=:::mom ................................ .... .... ■ ■ ■. .■■■■. ................................�.■■EM.■.■.■n ■■■■.■■N■■ ■■■■ ■ .................■.................... . ■... ■■■.■■■.■■.M■■■■ ......................................��.�■EE :u:::M:::::: : ■.■.■■■..■............n....■e...■. ........ ■■■■....■.■.■....■..■........■.....�iMMMMMNMMMMMMI ■■.■C■.■■!■■..■■ ...................................■..■..■�.... win M..I........■ ..........................■......■_...■.�■ ..■. ■ ■ .. ..■■■.■■ ................................ ..... ..... .....■■.......... ..................�.. O■.■��.■...■.■.■MEMEMEM■..■.■. EMNON iiiiiii iii�iiiiiiii�iiiii��iiiieii �iiii' ii"=iiii�ii'.=ii'■�'ME ■■■■■■■■■■.■■■.■■■■■■■■■■■..7■►\■■.�■.■■■■■ ■■■■ ■■■■■■■■■ ■■.■■■■■ ■■..■.■..■■■.■.......■■■■ ■\!// l�1/..■/. NOUN��..■■■■■■�■■.■■.■■ ■■■.■■■■■■■■■■■.■■■■ ■■■■■/*■o1�1►Y%1■■.■■■■■■■■■■■■■■.■■■■■.■■■.■■■■■ Noma ��■��i��i��MENEM