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1091 Baileys Chapel Rd (2) • 1' �' DAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION 1/ / •Nf}TE:Issue' d in Compliance With Article II of G.S.Chapter 130a ; Sanitary Sewage Systems �j,: �% Permit Number Name r' I :.,� ✓// . , f: Date N2 8186 Location �r'✓— �� - r' < 1�`. ,•; ---- v� ODS Subdivision Name Lot No. Sec. or Block No. Lot Size 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 ❑ �! 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, ✓Grr This permit is subject to revocation if site plans or the intended use change ATTENTION: YOUR SEPTIC SYSTEM CONTRACTOR MUST SEE THIS PERMIT/LAYOUT BEFORE INSTALLING THIS SYSTEM. 1- 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. .on day of completion.Telephone Number: 704-634-5985. Final Installation Diagram: System Installed by —�� Z"_=4- Certificate of Completion —_ Date 77– '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 give period of time. • APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMI D -0. Davie County Health Department Environmental Health Section P. O. Box 665 AUG 3 11995 Mocksville, NC 27028 ENVIRONMENTAL HEALTH .�, DAVIE COUNTY 1. Application/Permit Requested By IOdd 2; te./ Mailing Address 116 1-0-ke-VIPLo RoQCA Home Phone 99?-%S6, maCkso I le NC WoWe Business Phone 2. Name on Permit if Different than Above — J 3. Application for: ❑General Evaluation CI Septic Tank Installation Hermit 4. System to Serve: Lil House ❑ Mobile Home 0-Place of Public Assembly ❑ Business ❑ Industry ❑ Other ❑ Unknown 5. If house, mobile home: Subdivision Section Lot# /asement/No asement/Plumbing No. of People �- Plumbing No. of Bedrooms Vashing Machine No. of Bathrooms a• 5 Dishwasher Dwelling Dimensions / -7� ElGarbage Disposal n 6. If business, industry, place of public assembly, other: Specify type 'r1°Q A 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 q•& AC res 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: rrorn NAY k01 50�� I, 1 urn I-ic�� bn�o i leis 0 a e-1 �d s crox( rr �-emi le on r-'t , 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 a/pplplication. /( -) lJ DATE SIG URE CONSENT FOR SITE EVA UATION TO BE DONE ON ABOVE DESCRIBED PROPERTY Fandd 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 Davie ounty Health Department toe ter upon above described cated in Davie County and owned by_N 1(en-Codd ,Q i (P-(f %, C'i ,� Ltd-�-Ie(t all testing procedures as necessary to determine said site's suit bility for a gro nd absorption swage treatment al s stem.- 4- � J DATE 16IATURE DCHD(1193) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section . Soil/Site Evaluation Y NAME DATE EVALUATEDA ADDRESS PROPERTY SIZE PROPOSED FACIILTY Ag Are LOCATION OF SITE Water Supply: On-Site Well _ Community Public Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3 4 Landscape Rosition L Sloe R HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH e f:F r- Texture groupC-- Consistence Structure Sb/[ S /L Mineralogy 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 SITE CLASSIFICATION: EVALUATED BY: •�`Y�� 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-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-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 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 ■■.■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■.■■■■■■■■■_■■■■■■■■ ■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■..■■./■ ■■■..■■■�■�■■■■■■■■■■■■■■■■/■ ■■ ■■■■/■■.■■■.■■■■■■.■■■■■■■■■.■..■■■■M■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■..■./.■.■■...■.■■.■■■■.■.../■M. 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