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271 Jones Rd �a-��">� �-, _I•: ... _ ._ .. ' �-- fib... DAVIE COUNTY HEALTH DEPARTMENT 160 3:30` 4 d}" 'IMPROVEMENTS' PERMIT AND CERTtFICAE 'OF COMPLETION . 'NOTEAssuedrin Compliance With Article II of G.S.Chapter 130a r Sanitary Sewage Systems Permit Number Name -2 �2k_ N2 .7988 Location 5= mo S Atrn trig t5 � cl . � ��vC4�fiK.O --n ""`t+._,.• r- .5+1 .7"^— r., . V. s�+�`'�J:,a 1"'�� `.JJ 'i•+•.`:vn �' Subdivision Name ' j Lot No. . or Block No. Lot Size, - — House Mobile Home _ __ Business Industry No. Bedrooms —.No. Baths _ No.,,in•Family ' _ Public Assembly industry- 0 Garbage,Disposal YES. VNO '0Syste ,[ Sp cifications` fob =m: Auto Dish Washer YES, ❑ J 'Auto Wash Ma^hine YES 0 I r Type Water Supply Thin 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 SEE THIS PERMIT/LAYOUT BEFORE INSTALLING THIS SYSTEM. ( 1f rf" i. Improvements permit by ? — • I. *Contact a representative of the Davie County,Health Department for final inspection of this system between 8:30-9:30 A.M., r 1:00.1:30 P.M. or 4:30-5:00 PM.on day of completion.Telephone:Number:704-634-5985. k Final Installation Diagram: , .( .. System Installed by — lu ! at a .�-� - - til y � ' • • - '' Certificate of'Completion' Date t. 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. Al APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMI Q '-' d� Davie County Health Department * Environmental Health Section P. O. Box 665 c� Mocksville, NC 27028 -- ��DAVIEEC�OUN HEALTH 1. Application/Permit Requested By re o111,15 Mailing Address W 11 11 , C Z Home Phone —66 OF C Yin ma h s 1 V • C 27 1 Business Phone 2. Name on Permit if Different than Above 64 101 P- 3. 3. Application for: ❑General Evaluation i.N<ptic Tank Installation Permit 4. System to Serve: ❑ House obile 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 13 SIVashing Machine No. of Bathrooms ishwasher 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 W ter Usage Figures 7. Type of water supply: Public Private ❑ Community 8. Property Dimensions 2' �-• Sewage Disposal Contractor 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes 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: Owl, This is to certify that the information provided is correct to the best of my k wledge, and I understand I am responsible for all charges incurred f m this p licktion. DATE SIGNATURE CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY MUST CHECK ONE: ❑ 1. 1 OWN the property. 2. I 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 represent iv f the D ie unty�lealth ep ent t enter upon above described property located in Davie County and owned by � b to conduct all testing procedures as necessary to deter a said site's sui ability for a gro nd absorption sewage treatment and 'spoI„s tem. ( �{` DATE SIGNATURE DCHD(1/93) • �r DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section MSoil/Site Evaluation NAME l) es�A E� �- toa\ \`\� DATE EVALUATED �j y + �� ADDRESS PROPERTY SIZE PROPOSED FACIILTY � 'C\6 \hpp LOCATION OF SITE 737 Water Supply: On-Site Well ✓ _ Community Public Evaluation ByC"Cr_L_ Auger Boring l/ Pit Cut FACTORS 1 1 2 3 4 Landscape position Sloe % Fs •N'3- s° HORIZON I DEPTH - ` \2Y " \ � Texture group Ct.%_ �- Consistence --IF-:y Structure C Mineralo HORIZON II DEPTH Texturegroup >� Consistence `�—�- Structure �-- Mineralogy V. HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS Sj RESTRICTIVE HORIZON SAPROLITE -- CLASSIFICATION .S • .S ,S ,5 LONG-TERM ACCEPTANCE RATE , A SITE CLASSIFICATION: �� EVALUATED BY: LONG-TERM ACCEPTANCE RATE: \ OTHER(S) PRESENT: REMARKS: LEGEND Landscape 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-Vc-y 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 3C-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 ................................ ......■.�■_..■■■■.■■■■■■■...■.■■ ..................................■........■...■.........■...■■■EM ....................................■...■..■■..■■.■...■.■■■■..NONE ■........■■■..■......■............ME..N■.o EEE.■E■■ ■■EEO■.E■■EO■ ■■..■.■■■.■■■.....■o.......N.... t.■.■M..EO■O■O■EEOO■■■NE■EEO■■■■ ■■■■.....■..t../■.■t..■■...■...■ ■■■.■.■■EO■■■.ENOO.N■■■■...■NEON .......■................... ................... ..■. ■■■■■■■■■■■.. ■.■■■■■sE■■sOO■■■■..■E.■■■■nO!■■■■O■■■■.■■DODO ■sMENNE ■■MO■MEME■ ■.■.■■■■■■■■■■OO■MM■...■..■■■■M■■■■M■■■■M ■■■ ■ mammon OE■■EME ■■ ■.EEO■.M■.O■OO■■■DEE..■EN.O■E■■EO■EOEEME�■E■N ■N ■■■ MM■■O■u�■■ ■..■■....■■.■..■■■■...■■...■■.MO�■■■NE■sNO.EEOMOO■OM■s■EEOM■ENE■ ■■OO■■■t■■O■■DEE■EEEE■■■■■■M■EO■s■OO■sOOs■■H■■�=='_N:ON M:::MMON: MEN!■.....■..■..■..■■...■■/...■.■■■■O■■.....o..■.t■ ■■E■■■NM■■■OEOO..■■MMM■.■■■■■■■M■■■OE■O■ ■■■E■■■s■C■MEMONNEON■■■OO ■...E.■■DOM■■O■■■■�O�O..■■n.O■■En■ ■ ■MM■MMMMMMHMMM■MMM ■ ENNEE :::::::::::'.::ONE CONE:::NEON ::: .......■0.......................�.......N�...N.N........ 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