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200 Boxwood Church Rd Lot 7 v O c - .'DAVIE COUNTY HEALTH DEPARTMENT �b0 IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION Loi . *NOTE:Vued in Compliance With Article 11 of G.S.Chapter 130a ` Snitary Sewage Systems Permit-Number Name 7"Z h'41-0 R:A\Ucc.1 Date. N27434 Location NN. ,r Subdisiofi3Vame Lot No. Sec.or Block No. Lot SizeHouse Mobile Home Business industry No.Bedrooms No. Baths No. in Family Public Assembly Other Garbage Disposal YES ❑ NO p' Specifications for System: Auto Dish Washer YES p' NO ❑ �( r.,c ti> �).c *ti �" v, Auto Wash Ma:hine YES (D/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. 1 1 — 1C� Improvements permit by .cSs3s, *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--- L1 y-- )T. J t1 Certificate of Completion �(� Date J - L�k, '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. °tt�"' c aF:1e4T.�f}^V''fe-i'ivk ',..b%, a-... �� -- u . a,s. - - Y ,•v--. _- - ; —;' v,K .r ... -'; "^ '.•w*sY •t. ,� - ♦. .. .+t* tee; .., .. , _., .. DAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION fr / . *NOTE:Lgsued in Compliance With Article I I of G.S.Chapter 130a S nitary Sewage Systems Permit` Number Name c� \�•A\v c c..� Date � - �� �� NO 7 4 3' Location �� ti 4 (� 7 4 Subd`v sio amp Lot No. Sec. or Block No Lot Size U House Mobile Home Business Industry No. Bedrooms No. Baths _ — No. in Family Public Assembly Other Garbage Disposal -YES ❑ NO p' Specifications for. System: Auto Dish Washer YES ©` NO ❑ /C .: Auto Wash Ma^hine YES NO ❑ -:.2(�U� i �.�,.�_ �. '`�� Type Water Supply h - , *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. l YI Improvements permit by �,rs� " tzJ . t ' *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. r Final Installation Diagram: System Installed by — �`' R 20 �3 Certificate 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 R EC E 0 V E Mocksville, NC 27028 FEB 14 1994 1. Application/Permit Requested By e /1J 6 e U c c --------------- Mailing Address�7- k 6 Home Phone a Sil- yB 2 e etre//-e c• X 70 2 Business Phone 2. Name on Permit if Different than Above 3. Application for: ❑General Evaluation )Zi Septic Tank Installation Permit 4. System to Serve: ❑ House �9 Mobile Home ❑ Place of Public Assembly ❑ Business ❑ Industry ❑ Other ❑ Unknown 5. If house, mobile home: Subdivision Section Lot # ❑ Basement/Plumbing No. of People jr ❑ Basement/No Plumbing No. of Bedrooms )31 Washing Machine No. of Bathrooms a 1� Dishwasher - Dwelling Dimensions sp 41 X a ❑ 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: $1 Public ❑ Private ❑ Community 8. Property Dimensions 11 C f`�"� Sewage Disposal Contractor 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? 1] Yes ❑ 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: c&.{ Qat � � w✓�� �'� �'�..,s 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 TM BE DONE ON ABOVE DESCRIBED PROPERTY Fanddisposal ECK ONE: 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 Davi p C�ryyealth Department to enter upon above described cated in Davie County and owned by Z 1 e. 4,2 Yom/ e e (� all testing procedures as necessary to determine said site's suitability for a ground absorption sewage treatment system./4 9C DATE SIGNATURE DCHD'(1/83) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation NAME l�e 2 N`cr`11;�%111-4 "A C C�\ DATE EVALUATED ADDRESS S PROPERTY SIZE 11 � PROPOSED FACIILTY `�' 'P LOCATION OF SITE Water Supply: On-Site Well Community Public Evaluation By�"_'-1— Auger Boring ✓ Pit Cut FACTORS 1 2 3 4 Landscape position Slope % _V d q° -FSS HORIZON I DEPTH )D" 8'' Texture group C\. S Cl. S C L Consistence t -I I CZ F- Structure Q1. �11 Mineralo 1' \ \'. VA ,` HORIZON II DEPTH 3 8 4 1 LA Texture group C C Consistence Fs 1' a- 1=� Structure Y�K 4k'Ell 1� Mineralogy1 I 1 HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS 5 s s -S ss sS RESTRICTIVE HORIZON — _ — SAPROLITE — — CLASSIFICATION 5 LONG-TERM ACCEPTANCE RATE , �, LA X7 SITE CLASSIFICATION: �S EVALUATED BY: �\ LONG-TERM ACCEPTANCE RATE: y OTHER(S) PRESENT: N N REMARKS: �� 1 •� o, �ao�. Q� rr� \� 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 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 DCHD(01-901 CCiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiii■iiiiii iiiioiCCiiiii MINN■ ■.■■■.■■.■.■■■■■■■■■■e■■■■■■■■.■■.■■■■■■.C■■.■■.C■/E■E.■■■■■■■ ■■■■.■/■■■■■■■■■■■./■■./■■■.■.■UNA ■■■■■■■■■■■.■■■■■EE■■■■.■tit■■■■ ■■■■■.■■.■■■■■■■■■..■■.■■.■■■.■■■■■E.■■.E■■■■■E.■■ ■■R■E■■■■E■■■■ ■■■■■■■■■■■■■■■■.■■■■■■■■■■■■■■■�■■.■■■e■■Ce■■■■■■e■■■■■■■Nei ■.■ ■■■■■■■■■■■■■■■.■■■■■■■■■■■NNIS■■S■■■■■■.■■■N■■E.■iS■■■.■. ■■.■■.■ ■.■.■■E■■.■■■/NOON■■■■i/NOON■i/■ MARE■■■■■/■■ N■■E■■■■..■EE.■E.■ ■■■■■■■■■■■■■■■.■■■■■■■.■■■■■■■■■■.NOON■■■NO■■■■E■■■■■■■.�MEMO.■■ CCCCCCCCCCCCCCCCCCCCCCsiiiisiiiiiiiiiiiCCCCCCCCriiiiC°■CCCCCCCCCCCC �CCCCCC�CCCCiC'�iiiiCCCCiiiiiiC ' iiiiiCUM.iiiiCi=Cn.C"iiiiii� ■■M■■■■■■■■■■■■■■■.■■■■■■■■■■i■■■■■■■■■■■■N■■■■■R■■.Eo■■■ ■.NOON.■ ■■■■■■■■■■■.■.■..■■■■■■■■■■■■■■N■■N■■NHE�O■■■■■■ n■R■■■ NORSE■■■ ■■■■■■■■.■E■■■■■■■■■■■■■■■■■E.■.■■■E.■ ■■ ■■■t■tt ■CE.O■■M/■N■■■.■ CCCCC:C:C:C:CCCCCC:CC:C::C:CC::CCCCC:C .C:C :CC� C.CMIMMIEN MEN ■i ■i■■.■■■■■■■uA■■■■■A■i■A■M■A■M. 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