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176 Gawain Way i s DAVIE COUNTY HEALTH DEPARTMENT /6u. Ov IMPROVEMENTS PERMIT AND CERTIFICATE-OF COMPLETION •NOTE:Issued in Compliance With Article II of G.S.Chapter 130a Sanitary Sewage Systems Permit Number Name�_ v 2 --� VZ �c _-- Date _ IJ N2 8101 Location J<,51711k . — — -- v Subdivision Name Lot No. Sec. or Block No. Lot SizeHouse — Mobile Home -- Business—_ Industry r, No. Bedrooms Baths Baths _—� No. in Family _ Public Assembly Other Garbage Disposal YES p NO 0'� ` Specifications for System: Auto Dish Washer YES p NO Auto Wash Ma^hine YES 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 ATTENTION: ;YOUR SEPTIC.SYSTEM.CONTRACTOR MUST SEETHIS PERMITILAYOUT BEFORE INSTALLING THIS SYSTEM: :r. J IN .�` �� ,� C •rte o _w`^� ^ C Improvements permit by *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 —X G C-. ` � G l Ce r,iticate 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.s,,, PPLICAT(ON FOR SITE EVALUATION/IMPROVEMENTS PE F� Davie County Health Department JUN 2 8 1995 Environmental Health Section P. O. Box 665 Mocksville, NC 27028 1I' it/ Q.a� - ' 1. Application/Permit Requested By -Sif-V c �ru Mailing Address ��6 VgLQC%'n Liq� Aot"kly k— Home Phone Business Phone 2. Name on Permit if Different than Above 3. Application for. ❑General Evaluation E Septic Tank Installation Permit i 4. System to Serve: O House Mobile Home ❑ Place of Public Assembly ❑ Business ❑ Industry ❑ Other ❑ Unknown 5. If house, mobile home:Subdivision Section Lot# ❑ Basement/Plumbing is No.of People ❑ Basement/No Plumbing s No. of Bedrooms . ❑,Washing Machine No.of Bathrooms ❑ Dishwasher Dwelling Dimensions y r �L ❑ 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: Pubiic ❑ Private ❑ Community 8. Property Dimensions I Q&rg lD0 ct c f 45 Sewage Disposal Contractor S. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes R No If yes,what type? f' i�• .i :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. q: Directions to Property: q. Fork CamML)n '+Y W '19Awgy 6y f Toe- road 36 ,a Loj- ' ?' GP i u" : m� les do �d�. road �a Ga�q�n \mon �Iq�-r , r ve . . 6e1.%rA rnobtve ,e 'hese nd�, g is .. .. �N '< 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_N 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 ;I 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(1/93) • DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation r� l o NAME DATE EVALUATED ADDRESS 9 PROPERTY SIZE p PROPOSED FACIILTY � •�� LOCATION OF SITE Water Supply: On-Site Well _ Community Public Evaluation By:(%-U-••Auger Boring Pit Cut FACTORS 1 2 3 4 Landscape position ---5 Sloe Z HORIZON I DEPTH Texture group Consistence Structure G(Z Cr- C Mineralo 1 HORIZON II DEPTH 3,1 S L " Texture groupe Consistence lr P Structure 5C L t Mineralogy ' HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texturegroup Consistence ' Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON J SAPROLITE CLASSIFICATION g� LONG-TERM ACCEPTANCE RATE , SITE CLASSIFICATION: ` •� EVALUATED BY: LONG-TERM ACCEPTANCE RATE: t OTHER(S) PRESE REMARKS: 1 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-Vl,.-y friable FR-Friable FI-Finn 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 -;C--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 HD(01-901 ■.■■■■■■..■■.■.■■..■■■■.■■■■.■■■■■■..■■E.■E. ....■..Ee......■.■■.■ ................................................■..■ ■EM■MEME■■■■■ ■.■.■.■..■.■■.....■...■■■■■ ..■.■■■.■.■.■■■■■.■ Room Roo■ omm■mmom IMMmMMMMMlMMMMMMMM moommEaaaaasaaaaaa■ s ■.■■■.■■■■........■.■■■..■....H ■.OM■OM.■■■■.■M■.■■■■■....■■■■■■ ■.■■■.■../...■...........■/.... ■...■..NE..■■.......■....■.■■.■ ...............................................a.a=■.■■.■■E■■o■■.■ .................................... .MUM mmom...■. ■■mmm ■mm■■m■■ ■.■...■.■....■■...■.■■.■■..■..■■.....■■.■■......■■.■ ■..■■..■■ ■■ ■■■■•■•■■■•■•■•■••■■■•■■■••■■E■■SEE■■E..n■aaa'".■asaasasa:MEaaa ■..■..■■...■■.■...■..N■E..m.■■m.■ERE■■■.O■■■.a�m■R■ ■■■■■■■■■OM isaaasasaasaaasaaaasaaaasaassaaaaasa0 a ummomamomommsa ..............■.....■........................... ■ sao■■■ ■M■■■■ a on ■.M■■■..■ asaa:saaaaaaaaaaa::aaaasaaa�saaaaaaaaaasa"'■•• �saa =s'aaasaasa MMEMMMEM as■aa.Hs:saas:aa::aaaaaaaaaa"ssasaa:saa:aaa:aa::s::aa:aaa"asaaa:aa:aaa:.:�s■�aaaa�asaaaa'asa:aaa:aaa:a:a:a■as�aassmaoam'mua'��uamosmaaiusaaaa:aasa aa:■ �■■.aaom■sas . aa ■ a"4imE■■om' : Oa :' sass■aN O ' aaaa:ua: a. aa ■..■■■�■■.■■.�■■.■.■�sE■/.■ ' ■■.■.■ ■■■■■■.■..■.■■.■.■■.■■Hm. ■■■■■■■MEMO ■ . ■■ MER■E■ MEN■.■■■■.E■.E.N■■mO■■E■■E■O■■M■■■■■ ■■ Om ■■■■■■■■ ■E■■■■■■■.■■■.■■■■■ ■■.O■.■■E.O■ ■ ■■ ■ ■. m■■m■ ■m aaaaaaaiaa■i■iasi■iaa"'aasai■si' a " 'MENNEN .......a....H...N...aMnH... a. aC�a.....aa ■■.■■E■Em■■■■m■E■.■■■■■■Om■■.■■■ MEN.■El■�■■E MONO■■.■■■.E■amM■■O.■HH■ ■■■ ■■■mOME ONE a no MOMMEMIS ■ E■ HE ■■■■■■ WHEMMEME ■...■■.■■■■E■■■■■■■■■.ass■■■a■■■m■ H ■■ Hm.■m■a ■■■■■En■■■■■EON.E■..t■■■ROOM/E ■ HME■■■ ■mommom■mm■■■uMEME■EME a�aasaasasaaaaa M :sagas mm a MEMO ■.■■.■■mNoamomommoomm■■omm■■■■m■Ms■ ■MMEMMEM mommmmom No MEN MEMN ME . ..■m..■■■ OMEN MEMO ENORMOUS Lon■.■■.■.■.E/.E\�/.1■i;?iilE■E��.■i'^.1:■ mill '�'�\N■■■■■..■.■■ no ■.■.m.EEE■ ■i►■/IYI:■!�..■■.111\�IC:7.'tiE► -\■■■■■N■■■ m■amtom■■/a■MENAIM■UZZEMMEMHa■MMERN ■� M\/.sEEMM■/a ■■■■■M ■ E■E.\I`!/.Ell■EEr/■Cm.■■■E.■.■ r �asa■MMM ■■MM■■■ ONE m ■■�t■Mac_ ■■ M■■■■_ ■��■E■E■■■ ■.■■■t ■■ M /■■11ii�7■Ei/..■■..■/�liE0■■EaM■E■EEE��W\E■K1WEMORME■ME. ■■■■■ ■■ ■EM.E.I�I►\■■.:1E■EE■lel ■E■ =MERE\ ■■■MMURP.■E■.■■■. ■■■■■■■■■■■■tOtt■■t►t�lt Ol�ltl�t��■Mt■■■■■/!:\N71\Ott■■Ott\lOtt\■Mt■t\�■t■ soon a0