244 Juney Beauchamp Rd TY� •+.h'y w ..{lye,:a.'. ! Yi" t' Y. l.wyr ..�.. - - -- ... -
'tet oJ, DAVIE COUNTY HEALTH DEPARTMENT , n ,
,. . .�-• f'. :-.- IMPROVEMENTS: PERMIT AND CERTIFICATE OF COMPLETION
*NOTEAssued in Compliance With Article 11 of G.S.Chapter 13ppa
anita Sewage ystems //(o F'2 os-f'Rd' 1-"30.9 y- Permit Number
Name, 4 � Date !Z? -,/V- No 7519 +
Location
Subdivision Name Lot No. Sec. or Block No.
Lot Size � House Mobile Home — Business _— Industry
No. Bedrooms _!!�Z _.No. Baths — — No. in Family — Public Assembly Other
Garbage Disposal YES NO ❑ Specifications for System:
Auto Dish Washer YES 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.
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
�pD Pf�C
l'
Certificate of Completion Date / O4K
*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 PERMI REcE�V+!E®
Davie County Health Department APR 1 1 1994
Environmental Health Section
P. O. Box 665
Mocksville, NC 27028 ---------------
1. Application/Permit Requested By (SYS yn-- 0,►'Q�7
Mailing Address Ki- L4 8 U4 Z 6 Z Home Phone gI M– 9V0 –Z Z 7�
U C uv rBusiness Phone 066 —7 — 4f�
2. Name on Permit if Different than Above
3. Application for: ❑General Evaluation ;3rt'eptic Tad Installation Permit
4. System to Serve: ,,.House ❑ Mobile Home ❑ Place of Public Assembly
❑ Business ❑ Industry ❑ Other ❑ Unknown
5. If house, mobile home: Subdivision Section Lot #
ZBasement/Plumbing
No. of People ❑ Basement/No Plumbing
No. of Bedrooms Washing Machine
No. of Bathrooms a —3 ;a4ishwasher
Dwelling Dimensions V19nuA-t- q/Garbage Disposal
6. If business, industry, place of public assembly, other: Specify type l
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: 'L/ublic ❑ Private ❑ Community
8. Property Dimensions cC-ow, Sewage Disposal Contractor
9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes VAO
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: !j$ ��r{$-� -j v Srr� r�✓C P Q�S �i�c. paw mcw �f pss-
rn14, �Vw d eauc6/ray /SGL
tie vide 5iic�l� 6 6¢� , Pass
Loc,►en 's
AS
`7 ke- /'1�-tJie,(des�1
G l(��j S r C6Yl$l�l8v%�. �j�'` ��•t` (/L t f-� �Y�l� ��.�
This is to certify that the information provided is correct to the best of my knowledge, an understand I am responsible for all charges
incurred from this a plication.
I(
DATE SIGN URE
CONSENT FOR SITE EVALUATION TO BED NE ON ABOVE DESCRIBED PROPERTY
rand
HECK ONE: I OWN the property. X2. I DO NOT OWN the property.
ecked Box #2, the rest of this form MUST be completed by the owner or a person authorized by the owner:
give consent to the authorized representative f the Davi C my Hea D Qartment to enter upon above described',
located in Davie County and owned by �/ a dk u_ �� )
ct all testing procedures as necessary to determir16 said site's suitability fora round absorption sewage treatment
osal sy to
ATE SIGNATURE
DCHD(1193) ,
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
f Soil/Site Evaluation
NAME DATE EVALUATED
ADDRESS PROPERTY SIZE
PROPOSED FACIILTY LOCATION OF SITE .
Water Supply: On-Site Well Community Public J
Evaluation By: Auger Boring Pit Cut
FACTORS 1 2 3 4
Landscape positionSlope Z f
HORIZON I DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH
Texture group _
Consistence
Structure
Mineralogy .- ! i•'! A
HORIZON III DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE e
SITE CLASSIFICATION: EVALUATED BY: G
LONG-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 watet' 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
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