398 Joe RdDavie County Health Department
I'D 1836 r� Environmental Health Section
P.O. Box 848
- 210 Hospital Street
O U Courier # : 09-40-06
Mocksville, NC 27028
Phone: (336) - 753 - 6780 Fax: (336) - 751- 8786
ON-SITE WASTEWATER CERTIFICATION FOR DWELLING
(Check One) Replacement Remodeling Reconnection
Name: 1)0'W1 Q I K0L ,' Phone Number,334-41 +4a'93 (Home)
Mailing Address: BClq . oL(Work)
h .
mqC �L�►i1 � � 2 1 y - Email
Detailed Directions To Site:
Property Address: -3q l J O o ry) W k'vi 0 p N L
Please Fill In The Following Information. About The EXISTING Facility: L�TTA 047�
Name System Installed Under: Type Of Facility:
Date System Installed (Month/Date/Year): Number Of Bedrooms: Number Of People:
Is The Facility Currently Vacant? Yes No If Yes, For How Long?
Any.Known Problems? Yes No If Yes, Explain:
Please Fill In The Following Information About The NEW Facility:
Type Of Facility:' a6�jc Number Of Bedrooms: Number of People_
Requested By: Date Requested:
(Signature)
For Environmental Health Office Use Only
Approved Disapproved —r -
Comments: f-t�mve �,��i (C.0 Q. -- m m.st hod -Cass �ss ovr, v cWa WQ.C2
—T-r�
an fWatr afUA- Gt;re 1 ne_e_4e cd. Irl. w-!� h+ cit 07 <WJ4;C__
Environmental Health
Date:
*The signing of this form by the Environmental Health Staff is orf no way intended, nor should be taken as a guarantee
(extended or limited) that the on-site wastewater system will function properly for any given period of time.
Payment: Cash Check Money Order # Amount:$_
Paid By: Received By: -
Account #: Invoice #:
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All data Is provided as is without warranty or guarantee o , aft r p se p lading but not limited to the implied
warranties of merchantability or fitness for a particular use. All users of Davie County's GIS website shall hold harmless the County of f'0 U V;
Davie, North Carolina, its agents, consultants, contractors or employees from any and all claims or causes of action due to or arising out of
5 the use or Inability to use the GIS data provided by this website. PCI n ted. J U 123, 2013
^Y .--•5 '4-`�j,;roi.. '7`v`(`'^• Z7-k"�"`-1, t Sid
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DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND' CERTIFICATE OF COMPLETION
*NOTE: Issued in Compliance With Article I I of G.S. Chapter 130a
S nitary Sewage Systems Permit u er
Name .� _ Date N2
ob
Location_ —
6 Ll
3qC9 JOF'i Rte—
Subdivision Name Lot No. Sec. or Block No.
Lot Size i House Mobile Home Business _— Speculation
No.`Bedrooms .No. Baths No. in Family _
Garbage Disposal..YES NO ❑ Specifications. for S stem. C`
Auto Dish Washer YES'' �j, NO'[] ' Y '�''` �\� y
Auto Wash Ma shine YES QJ NO ❑ Q 3 y; ( ; v ; :-`
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.
Improvements permit by
/% o
*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.
S
Final Installation Diagram: System Installed by _
h
�Wll/,pCertificate 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 PERMIT
Davie County Health Department
Environmental Health Section
P. O. Box 665
Mocksville, NC 27028
1. Application/Permit Requested By t L
Mailing Address 160 1 _ P t ✓�5 �.--
Home Phone j G ?_Z
2. Name on Permit if Different than Above
D c.k SV V.
3. Application/Permit for: ❑ General Evaluation
4. System to Serve: 10 House ❑ Mobile Home
❑ Business ❑ Industry ❑ Other
5. If house, mobile home: Subdivision
No. of People v
No. of Bedrooms `t
No. of Bathrooms ?
Dwelling Dimensions S
6. If business, industry, place of public assembly, other: Specify type
No. of People Served
No. of Commodes
No. of Sinks -
No. of Urinals
n r. T 2 6 1�Qi
& Septic Tank Installation
❑ Place of Public Assembly
❑ Unknown
Section Lot #
❑ Basement/Plumbing
❑ Basement/No Plumbing
&T Washing Machine
a Dishwasher
❑, Garbage Disposal
No. of Lavatories No. of Water Coolers
No. of Showers Water Usage Figures
7. Type of water supply: ❑ Public A Private
8. Property Dimensions q A-Cy`�-- S Sewage Disposal Contractor
9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes
If yes, what type?
M
❑ Community
'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:
This is to certify that the information provided is correct to the best of
incurred from this application.
/0- z (0 - t
DATE
Csa�nlG—
/,v
I understan0 am responsible for all charges
SIGNATURE
CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY
MUST CHECK ONE: ❑ 1. 1 OWN the property. li- 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 ol,.Ae avis ?!uniy Health Departent to -enter upon above described
property located in Davie County and owned by T2 Q_ 5 4 oN
to conduct all testing procedures as necessary to determine sa' site's suitability for round orption sewage treatment
and disposal system.
DATE SIGNATURE
DCHD (12-90)
' DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site"•Evaluation t C,
NAME AV \� �'� �� DATE EVALUATED
ADDRESS S A sk PROPERTY SIZE
PROPOSED FACIILTY O LOCATION OF SITE �b e
Water Supply: On -Site Well V Community
Evaluation By:(M Auger Boring Pit
Public
Cut
FACTORS
1
2
3
4
Landscape position
S
S
Slope %
b- o
G
HORIZON I DEPTH
"
"
S
Texture group
c
Z
Consistence
Structure
Q_
Mineralogy
\'Y
HORIZON II DEPTH
O`'
O+'
40
Texture group
c
C
Consistence
IF M
Structure
C�
Mineralogy
1
HORIZON III DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
SS
SS
SS
S S
RESTRICTIVE HORIZON--
SAPROLITE
S'
X
.S
S
CLASSIFICATION
2 SS
LONG-TERM ACCEPTANCE RATE
1.41
SITE CLASSIFICATION:y •�
LONG-TERM ACCEPTANCE RATE: LAI
REMARKS:
DCHD(01-901
EVALUATED BY: `l%lc ?,
OTHER(S) PRESENT:
..� � - Q,Q
LEGEND
Landscape Position
R -Ridge S -Shoulder L -Linear slope FS-Footslope 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.watef 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 '
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