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P6637 Joe Rd/ ,... . .:..r, .t-.. s. ..:f: ,. N',klrf +�•y s. < 6 . ..a,. .ar; ,.. .. .._, s .. ,' - DAVIE COUNTY HEALTH DEPARTMENT 1 IMPROVEMENTS PERMIT AND .CERTIFICATE OF COMPLETION *NOTE:Issued in Compliance With Article II of G.S.Chapter 130a Sanitary Sewage Systems Permit Number ZD Name �� f . J jri . JJ} ;G;✓ f ' Date �.�-" %'��- NO -7 Location ���'.� � .,.� �r` f �t7 U �r-.1�: t� ��� _ U ! Subdivision Name Lot No. Sec. or Block No. Lot Size House Mobile Home _T Business _ Speculation No. Bedrooms cV _.No. Baths _,Z No. in Family _ Garbage Disposal YES ❑ NO p— Specifications for, System: Auto Dish Washer. YES NO ❑ Auto Wash Ma thine YES [j NO ❑ 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 *Contact a representative of the Davie County Health Departmerit for final inspection of this system between 8:30- 9:30 A.M. or 1:00-1:30 P.M. on day of completion. Tele hone Number 704-634-5985. Final Installation Diagram: yste Installed by� �' Certificate of Completion � :A 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. r r APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT Davie County Health Department Environmental Health Section P. O. Box 665 Mocksville, NC 27028 1. Application/Permit�R7equested By, p � t ►� !� -S , /A)Cr Mailing Address r� o ,s Zit ,4 /1A IJ C.. lV,C' 9,0 0 1' Home Phone Q �3 417L� Business Phone 2. Name on Permit if Different than Above 3. Application/Permit for: eneral Evaluation RrSeptic Tank Installation 4. System to Serve: RT House ❑ Mobile Home ❑ Place of Public Assembly ❑ Business ❑ Industry ❑ Other ❑ Unknown 5. If house, mobile home: Subdivision Section Lot # ❑ Basement/Plumbing No. of People //7- ❑ Basement/No Plumbing No. of Bedrooms [O-Washing Machine No. of Bathrooms ❑ Dishwasher 0 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: P015ublic ❑ Private ❑ Community 8. Property Dimensions I L L wil e 41Y V>E-'F ° Sewage Disposal Contractor 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes o 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: lir' 'N Mo C,(eS v►L L F & Lf T SOC os. So E- Pcd 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. DATE SIGNATURE CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY Fanddisposal ECK ONE: LST 1. I OWN the property. ❑ 2. I DO NOT OWN the property. ked Box#2, the rest of this form MUST be completed by the owner or a person authorized by the owner: ve consent to the authorized representative of the Davie County Health Department to enter upon above described cated in Davie County and owned by all testing procedures as necessary to determine said site's suitability for a ground absorption sewage treatment system. DATE ' SIGNATURE DCHD(12-90) Forn,� r1iA-N1. 424-2 0- 15 .71) UNITED STATES DEPARTMENT OF AGRICULTURE Farmers Home Administration PROPOSED INSTALLATION OF INDIVIDUAL SEWAGE-DISPOSAL AND/OR WATER SUPPLY SYSTEM Name of Property Owner Property Address (If this property is in a development, give lot no. and block no. Number of bedrooms proposed Approximate area of lot square feet. House is to be set back feet from the boundary. I propose to construct on the above-captioned property an individual type sewage-disposal system well , .This installation will be constructed so as to meet all the require! ments of the local Health Department and the State Board of Health. WELL: Site location approved by Health Department ( ) yes ( ) no. Type Size of storage tank Drilled, Driven,, Bored, Dug) Make: Type and capacity pump: Septic system to be installed to accommodate: Garbage Grinder ( ) yes ( ) no Washing Machine ( ) yes ( ) no Date: (Signature of PropertyOwner) SEPTIC TANK: Working capacity Z9_9) gallons NOTE: If tank has not been specifically approved by the State Board of Health, submit plans and specifications. i PERCOLATION TEST RESULTS (If considered necessary by local Health Department) Hole No. 1 2 3 4 Minutes per inch of fall) SUBSURFACE ABSORPTION FIELD No. of nitrification lines; total len hfeet; width inches; total nitrification lines bottom area square feet. A_representative of the Health Department has inspected this site and finds it suitable unsuitable for the proposed installation. I Well Site bocation Approved by Health Department ( ) yes ( ) no. Date:_/�� — (Signature) (Title) If there 1s any pertinent information which the Health Department desires to convey to the reviewing officials, which is not covered above, use the back of this application. Return ori.;inal and one copy to Farmers Home Administration County Office. l DAVIE COUNTY H 'H EFARTMENT Environmental Health Section .Soil/Site,Eyaluation NAME ��'�L/ >�� DATE EVALUATED ADDRESS PROPERTY SIZE l PROPOSED FACIILTY /YJ'�l c LOCATION OF SITE Water Supply: On-Site Well r Community Public ------- Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3 4 Landscape position L__ 11 Sloe % HORIZON I DEPTH Texture groupL Consistence Structure Mineralogy HORIZON II DEPTH Texture group G Consistence Structure S'�s Mineralogy ` HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION S .LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: EVALUATED BY: ,V� LANG-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 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 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......ee.■■■Mee.■■M■..e..■■■■ o���������■���������������� MEMEME� MEMO=moommommmME� ■■■■■■■.■!■■...e....■■■...■■Mee■.■■■MEMO.■■■.e■■■■■.■■■■■■■■■■■■.■ ................................�.............■.... 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