P8114 Ken Hoots Ln DAVIE• COUNTY HEALTH .DEPARTM,E;NT
IMPROVEMENTS .PERMIT AND.:CERTIFICATE 'OF. COMPLETION
` 'NOTE:Issued intompliance With Article II of G,'S.Chapter 130a._
fSa nary sew ge 7jems, ',; ;' Pertmit Number
Name N20
Location ' _ r
1 l,,l �:',a f l �' •', ,c ! 7l { !�t: C 5` .c� /' f ���i� / 1�' f
Subdivision.Name �I'' Lot.No., 'Sec. or-Block-'No..,
Lot Size /�'1. _ House Mobile Home•_ --Business _- Industry
No. Bedrooms, _-.No; Baths No. in Family _ Public Assembly, Other
Garbage Disposal YES NO p -
Speciflcatlons for System: y'
Auto'Dish Washer YES NO. ❑ �, tr .,`c' f `. d>! '
- Auto Wash Ma^hine YES NO [] • ` �'' `� • ,t,
Type Water. Supply - -- ---
*This permit Void if sewage system described below is not installed within 5 years from date of issue.
Thi s`permif is subiect to revocation if site plans.or the intended use change
ATTENTION:'. YOUR SEPTIC SYSTEWCONTRACTOR MUST SEE THIS PERMIT/LAYOUT BEFORE INSTAWNG THIS
SYSTEM.
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., l
1:00-1:30 P.M. or 4:30-5:00 P.-M.On' day of completioni4elephone Number: 704-634-5§O.$"60
Final Installation Diagram: y, y k
S stem Installed b
Certificate of'Completion' __ Date '��y�
'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 N0 way be'takemas a guarantee that the system will function
,satisfactorily for any given period of time. I
114r wilt
'9�. APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PE
�OJ j�' Davie County Health Department t5 1J
/}� Environmental Health Section
,/ P. O. Box 665 +» 5 1995
Mocksville, NC 27028
1. Application/Permit Requested By ��n tl 1 e Led-�o i,-cl
Mailing Address P a o �-3 Home Phone 9 9)- 4'5 7
A clyancxe AC �j oo(o Business Phone (1,92- LILS 11�L
2. Name on Permit if Different than Above
3. Application for ❑General Evaluation Septic Tank Installation Permit
4. System to Serve: ❑ House 0 Mobile Home ❑ Place of Public Assembly
❑ Business ❑ Industry ❑ Other ❑ Unknown
5. If house, mobile home: Subdivision Section Lot #
❑ Basement/Plumbing
No. of People 13 ❑ Basement/No Plumbing
No. of Bedrooms 3 Er washing Machine
No. of Bathrooms -21 C-6ishwasher
Dwelling Dimensions 9 x 47 C>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: Public ❑ Private ❑ Community
8. Property Dimensions 7 QGf-GS Sewage Disposal Contractor
9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ 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:
Go +o A c kd t,cc-
(.lnde,-pcllss Rd - /-51- dr�,rG on l -F - K Noes L4 he. - ac.i-oss -Ae
I"at 1lroad 4-r-octs - ),nd drive. arN IcI4
This is to certify that the information provided is correct to th a of my knowledge, and nderstand I am responsible for all charges
incurre from this application.
_ 3 -�s 'IA4
DATE 63S RE
CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY
MUST CHECK ONE: ❑ 1. 1 OWN the property. P 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 C unty He�Ith Qepartr�ent to enter upon above described
property located in Davie County and owned by. A,5e-t $- gato r-�drlCral
to conduct all testing procedures as necessary to determine said site's suitability for a ground absorption sewage treatment
,and disposal system.
t� 3 ' '
DATE �—' SIGNATURE
DCHD(1193)
DAVIE COUNTY HEALTH DEPARTMENT
4 Environmental Health Section
Soil/Site Evaluation
NAME �i`f7l el DATE EVALUATED
ADDRESS PROPERTY SIZE
PROPOSED FACIILTY /t LOCATION OF SITE ��Lj�iu�4- .C/Y
Water Supply: On-Site Well _ Community Public 41
Evaluation By: Auger Boring Pit Cut
FACTORS 1 1 2 3 4
Landscape position L
Sloe % 6Z
HORIZON I DEPTH 1
Texture &roup
Consistence
Structure
Mineralogy
HORIZON II DEPTH t" y
Texture group
Consistence
Structure
Mineralogy : i
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 RATEJ q I
SITE CLASSIFICATION: EVALUATED BY: .
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 <.-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-Nonplastic 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
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