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170 Joe Myers Rd Z,7-4 60 DAVIE COUNTY HEALTH DEPARTMENT J 'bo. IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION' , •NOTE issued in Compliance With Article 11 of G,S Chapter 130a Spit Sewage Systems t h Permit Number Name_ `� �'S -- Date N2 799 Lo�cat(ion�� Subdivision Name LOI.NO. Sec. or Block No. s Lot Size `?_` — House - Mobile Home _ _ Business -- Industry = No. Bedrooms --.No. Baths — —.No. in Family _ Public Assembly Other Garbage Disposal YES ❑ NO Specifications for,System: . Auto Dish Washer.,, YES' ❑ NO. [�'�.� f•�_� r:�c, r,EY� �,�`�:� � . �� Auto Wash Ma^hine. YES (g� NO � -- i `X' 10 4 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 o,r.the,intended use`change ATTENTION: YOUR SEPTIC SYSTEM CONTRACTOR MUST SEE THIS PERMIT/LAYOUT'BEFORE INSTALLING THIS SYSTEM.' a��' S r� i rr b kdfi, do, Improvements permit by la a `Contact a representativecof.the;Davie=County Health Departmentfor�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 _ Certificate of„Completion __ Date ZZZ4.2n:-�- 'The signing"of this certificateshall 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 PERM c Davie County Health Department Environmental Health Section 4 P. O. Box 665 IM Mocksville, NC 27028 1. Application/Permit Requested By (�1,/A��{V Mailing Address ��0 �Tn -t; A&VV S/1 d / Home Phone d l`(j_Lj G t° S �d O !� Business Phone 2. Name on Permit if Different than Above 3. Application for: ❑General Evaluation / dSeptic Tank Installation Permit 4. System to Serve: ❑ House �Mobile 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 "ashing Machine No. of Bathrooms ❑ Dishwasher Dwelling Dimensions 12- J 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 Private Gown Community 8. Property Dimensions (�,'r5 Sewage Disposal Contractor ems 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes . 99"'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: �O fly rs R r/ro- a/'/1x11tJz r Q 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 his application. (� li E SIGNATURE CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY MUST CHECK ONE: 4r 1• I 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 avje ounty alth Department to enter upon above described property located in Davie County and owned by to conduct all testing grocedures as necessary to determine said •e's suita dity for a ground absorption sewage treatment and disposal system. ' q-r'7— DATE SIGNATURE DCHD(1/93) Jj ,_ r DAVIE COUNTY HEALTH DEPARTMENT s Environmental Health Section Q Soil/Site Evaluation 1� NAME y J DATE EVALUATED ADDRESS S Acre PROPERTY SIZE PROPOSED FACIILTY V\ LOCATION OF SITE_7S� Water Supply: On-Site Well _ Community Public Evaluation By.�_'ZAuger Boring Pit Cut FACTORS 1 2 3 4 Landscape position S Sloe Z SS- g- �5� b HORIZON I DEPTH LZI, Texturegroup CL L _ t- C-1 ConsistenceF ti Z , Structure Mineralo HORIZON II DEPTH 56 6 Texture group Consistence Structure '3� Mineralogy HORIZON III DEPTH Texture grouR Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS -S-S .SS RESTRICTIVE HORIZON — - SAPROLITE — -` CLASSIFICATION S. S LONG-TERM ACCEPTANCE RATE 1 3 3 1 SITE CLASSIFICATION: � � 5 EVALUATED BY: � LONG-TERM ACCEPTANCE RATE: OTHER(S) PRESENT: N a tJ ,q- REMARKS: 4Ab .�- rt w►$ R.,� 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-V+--.ry friable FR-Friable FI-Firm VFI-Very fine 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 Mineralog 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 ■■■■■■■.■■■.■■..■■■■■.■.■■■■■■.■■.■.■....■.■/../e=■.■../.■ ..M...■ ■■■■■■■■■■■■ ■■■...■■■■.■.■■■■■■ ■■Ross./..■....■........■■.....■ ■■■.■.■■■.■..■MMM■MMMM■MM■■■EM■M.■.E■..■...■ ■e..■....■■..■..■.e.■ ...........................................�■.■....■ ■..■■.■..■.■. ■■■■■■■.■■■■.■.■■■■■■■■■■.■■■■■. 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