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176 Sycamore Ln (2) Vko DAVIE COUNTY HEALTH DEPARTMENT 00 HE if IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION *NOTE:Iss ued in Compliance With Article I I of G.S.Chapter 130a Date Name NO Subdivision Name Lot No. Sec. or Block No. Lot Size House Business Speculation No. Bedrooms No. Baths —7;7 No. in Family Garbage Disposal YES C3 NO (p,, Auto Dish Washer YES a NO C] Auto Wash Ma-1hine YES NO C] Type Water Supply *This permit Void if sewage system described below is not installed within 5 years from date of issue., This permit iosubject torevocation ifsite plans orthe intended use change. . , ' L� ' ST.4r) ' ' ' . ` � ^ t� . Improvements permit by ~Contactu representativeofthe Davie County Health Deportment for final inspection of this system between 8:30- 9:30 A.M. or 1:00'1:30 P.M. on day of completion. Te|ephoneNumbor 704'834-5985. Final Installation Diagram: System Installed by � ��`� ^' � , /^ /� /| 0 �]\ +f . � ~ / ' � � ' Certificate mfCompletion --~^- - - Date . 'The signing of this certificate ohnU indicate that the system described above has been installed incompliance 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 mftime. �► 7� APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT Davie County Health Department C/� I Environmental Health Section n / f P. O. Box 665 AUs S i Mocksville, NC 27028 -------------- - 1. Application/Permit Requested By 5 Mailing Address� fi �� N1c�-'�-Sv 1 le N�. D-1 Q8 Home Phone�� Ll 1 1 acgLr " Q92(o Business Phone L-)ULt ) �� QS /q 2. Name on Permit if Different than Above 3. Application/Permit for: WGeneral Evaluation 1?Teptic Tank Installation 4. System to Serve: ❑ House G f lobile 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 ��^ lWashing Machine No. of Bathrooms Q'(/ ❑ Dishwasher Dwelling Dimensions ❑ Garbage Disposal 6. If business, industry, place of public assembly, other: Specify type N No. of People Served No. of Sinks No. of Commodes No. of Urinals No. of Lavatories No. of Water Coolers No. of Showers Watters Usage Figures 7. Type of water supply: El Public Lel'Private ❑ Community 8. Property Dimensions ate. Sewage Disposal Contractor 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes D40 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: .a 101 .E r d1eex�n�- Y 1Jol � � ,a V .�- c��nSL nn r cypaq �� --�-1 c co ti b�, t1e5 t - � 1Gx cl �� 1 � IZ rn , _ 00 �� r d r hI c Q MCS` P Cie OAU A oc\ W\r\4 e 4V)e erd a4v-,a)ad, 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. r DATE SIGNATURE CONSENT FOR SITE EVALU&TION TO BE DONE ON ABOVE DESCRIBED PROPERTY Fanddisposal ECK ONE: P<I OWN the property. ❑ 2. 1 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 SI URE DCHD(12.90) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation NAME _ DATE EVALUATED ADDRESS S a PROPERTY SIZE PROPOSED FACIILTY `' �� ` ° LOCATION OF SITE Water Supply: On-Site Well Community Public Evaluation By: (Z� Auger Boring V Pit Cut FACTORS 1 2 3 4 Landscape position L77 Sloe % O - o-j -Sa o, go HORIZON I DEPTH " " is Texture group Consistence T. Structure �. MineralogX HORIZON II DEPTH Texture group Consistence IF a FZ Structure ¢\B k $ Mineralogy1'• l 1 ► ' i HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON -y SAPROLITE CLASSIFICATION Ce S LONG-TERM ACCEPTANCE RATE ,1+ r 1 SITE CLASSIFICATION: EVALUATED BY: �' - LONG-TERM ACCEPTANCE RATE: OTHER(S) PRESENT: REMARKS: _ .A � y- ! s" t 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 Mineraloety 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 CC:C:CCC:CCCCCCCCCCCC::::CC:CC:CCCCC:CCCC'C�CCCCCCC�CCCCCCCCC:CC CCCC'iiiieiiC'iiiiiiiiiiiiCCCiiiC�iiiiiiiiCCCii.iiiiiiiiiiiii■■CCC .................................................■................ ................................ ................................ 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