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1059 Ben Anderson Rd DAVIE COUNTY HEALTH DEPARTMENT I�d " ,r" G► IMPROVEMENTS PERMIT AND CERTIFICATE—OF COMPLETION''., *-NOTE:Issued in Compliance With Article II of G.S.Chapter 130a m°ri Sanitary Sew -S stems Permit Number Name Jc:' A tJ r S�k 4?s Date / N2 ' 7745 Location � - I \ l� k,y 601 N ! t4r Y.� hRc� � � �.�_-�,. V <\� QAC CC -,k ' c*<. eq4v) Subdivision Name. \ Lot No. Sec. or Block Nod. 7 \ Lot Size 3 House Mobile Home Business _— Industry No. Bedrooms :No. Baths — °�No. in Family -P,_ Public Assembly it h r Garbage Disposal YES ❑ NO Specifications for System: _ Auto Dish Washer: YES:,❑ NO ❑ / cvv c, G�a�+ '+ _ @� Auto'Wash Ma;hive YES 'p/ NO ❑ ' T X u ,��t SUS Type Water Supply W , _— *This permit Void if sewage system described below is not installed within 5 years from "N *This issue. This permit is su1bject to revocation if'site plans or the intended use change. 0-0 Improvements ,Y i r; 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 �C vFtO Z. +` ( 11,, •f Certif cpte of Completion \ Date J5 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 aL guarantee that the system will function "satisfactorily for any given period of time. I`X\m do ) o', 00 APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PE 2 a ' Davie County Health Department 15 Environmental Health Section P. O. Box 665 SEP 2 6 Mocksville, NC 27028 1. Application/Permit Requested By T Mailing Address g 6/QD L4 �c✓• _Home Phone .G EX/�lG/Drt� C 7,7 9-2 Business Phone g/D- '7•S// /�O(�/-/3 PM 2. Name on Permit if Different than Above 3. Application for: — ❑General Evaluation 9 Septic Tank Installation Permit 2/ 4. System to Serve: 2 House ❑ Mobile Home ❑ Place of Public Assembly ❑ Business ❑ Industry ❑ Other ❑ Unknown 5. If house, mobile home: Subdivision Section Lot # ®'B-�asement/Plumbing No. of People ❑ Basement/No Plumbing No. of Bedrooms 3 G?Washing Machine No. of Bathrooms a ❑ Dishwasher Dwelling Dimensions W/4 AayZ A✓aT SAM&A CW D E$/6AJ ❑ 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 2"P rivate ❑ Community 8. Property Dimensions i/ —dne&r Sewage Disposal Contractor }/AVE /t/ 5,eA1 a&C. 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes 01110 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: 0/ Alt /—45F'7-45F'7- 40AI r y l 'Z46'T D/' X5411 Cleg6o<' ,Oecl/ Ae6G/1- 7 " Ovzl 1 x'1dAJ- o�7— 6,9726. l� ?L7"0 i2 G 9OR.6 E W if L5On/ I-MX -0 Ineo7-- �Srl�f//Ti4�/fin! /4T A40AUTy I9�.� �"/mg /9n/® 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 t is application. DATE SIGNATURE CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY MUST CHECK ONE: ❑ 1. 1 OWN the property. &112. 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: y-- 1 hereby give consent to the authorized representative of th Day unty alth Department to enter upon above described property located in Davie County and owned by /�� , to conduct all testing procedures as necessary to determine said site's suitability for a round absorption sewage treatment and disposal system. �R - 9Y DATE SIGNATURE DCHD(193) v Lv i 0 c 9� a9�� "�E5 4'•+ � O •r+��i' 'y - aI�Y f 7. I A6f. � N _ cr /fl:cAc) I v a 23 .73.EL6 AcG ?p�N t �. coI� i. ,..♦ / o 0 ( Ac. G Lo f 17 4"Y f :r 75 i -0 YS rf �• L' Y i� .1.^� 4✓ _nom 64�. •Qa .�• �. .. } a , t.{ 'r* '-:yam`✓r ♦ -'++ fi 1�t ' LP �fV"• Y � Y pt- . .111 � /* p "'=r.• DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation c� NAME `Z� AN `(�K�'R�4S DATE EVALUATED ADDRESS S PROPERTY SIZE I CJsJ� PROPOSED FACIILTY )L\0 V 5 Q LOCATION OF SITENa�u� Water Supply: On-Site Well Community Public Evaluation Byt�zjU-Auger Boring Pit Cut FACTORS 1 2 3 4 Landscape position S S7 .S Sloe S- 6 " �� FS- HORIZON I DEPTH1P Texture group ( A- Consistence - T- I Structure Z C R- Mineralogy . 1 HORIZON II DEPTH Texture group Consistence 7 Structure Mineralogy ',� VI 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 ,4 SITE CLASSIFICATION: S EVALUATED BY: \ LONG-TERM ACCEPTANCE RATE: OTHEWS) PRESENT: �r REMARKS: _CR �- EGEND 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 (aay 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 3C-Single grain M-Massive CR-Crumb GR-Granular ABK-Angular blocky SBK-Subangular blocky PL-Platy PR-Prismatic Mi neraloQy 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(01-90) ■■■■■■■■■■■■.■■■■■■■■■■■■■.■■■...■.■■■..■■■■■■..■■■■■■■■■■ MENi■ ' MEMO ■■■■...........E■■■■.MEEi■■E./.%■ ■■EE■...00E\'E■O■E000■OOO..O■OOOi ■■.......■■.....■■■■...■■■■. ..■l: .....■.■...i�OIO■E.■OO.■...■■O. ■■e■■■■■■■..■■■E■■.■.■■.■■■..■��■■a■e■■e■■e�■■eeEeee■,■e■Ne■eeM■e■ ■■...■■......■...■.■.■0...■■.i.■.OM.....■...■■..■■ MM■■■MO■■■■■O■ ■i..OaOO.EO■.00iii■■..O...O...■O.O��1E■.O■.000..■/��O■O■■OOEO.■OOOC MENEM ■...■.■■t.■..■air.■�tE.■E■■■■ree■�I■■■.■■■■■1�.■■.E■M.■■....■..MC■on ■■■e■eeEMe■e■■/ir�l,�er�■EN■■e■Ea`aM■■■n■■e■■ee■■eneaal.l�►�Ere■■■eeeM■ ■.■...■■..■.■■/1/1 cJOI�■■■■■■■iii■■■■■.■.■0..........r. 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