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1120 Beauchamp Rd dr DAVIE COUNTY HEALTH DEPARTMENT �' = -IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION *NOTE:Issued in Compliance With Article II of G.S.Chapter 130a Sanitary Sewa�ge Systemsj, ,F �2 Perm NameP�v�_r�e�/°/ % �✓., u�i�ilvd/J /1'1 Date ND I—cL '� y '7it. Number 6 8 6 Location Y_ ✓�/�� r N '/liri//7iS'-rel F<' 1'� "�s✓ �� G Subdivision Name Lot No. Sec. or Block No. ve/7L Lot Size — House Mobile Home _ Business -- Industry No. Bedrooms _No. Baths�2 No. in Family— — Public Assembly Other Garbage Disposal YES ❑ NO Auto Dish Washer YES NO Specifications for ys em: Auto Wash Ma^hine YES NO ❑ /D�� 1 Type Water Supply *This permit Void if sewage s stem described below is not installed within 5 years from date of issue. This permit is subject to oca if site plans or the intended use change. A s - M rn a . Y • v n tt l Improvements„permit by — .M *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:7046345985. Final Installation Diagram: System Installed by 7-11W is Certificate of Completion ___, GY _ Date 'The signing of this certificate shall indicate that the system described above has been installed in compliance with A 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. J � _ •+ ! l gI f.C4l4N FOR SITE EVALUATION/IMPROVEMENTS PE Davie County Health Department AUG U 3 1994 Environmental Health Section P. O. Box 665 Mocksville, NC 27028 1. Application/Permit Requested By Mailing Address Home PhoneA—=� 71 , (2, U Business Phone 2. Name on Permit if Different than Above 3. Application for: ❑General Evaluation VSeptic Tank Installation Permit 4. System to Serve: 0-'House ❑ Mobile Home ❑ Place of Public Assembly ❑ Business ❑ Industry ❑ Other ❑ Unknown 5. If house, mobile home: Subdivision Section Lot # basement/Plumbing No. of People VBasement/No Plumbing No. of Bedrooms OWashing Machine No. of Bathrooms B/}TNRnoMS, ( WDE(Z }�(Li, Dishwasher Dwelling Dimensions r7PPBS�X �0� ❑ 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 t 8. Property Dimensions Sewage Disposal Contractor 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes XNo 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: �� 4_ 1^ 1 � , / Le- C 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 9 ` - DATE SIGNATURE CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY Fa:nd ECK ONE: ❑ 1. 1 OWN the property. ❑ 2. 1 DO NOT OWN the property.' ked Box #2, the rest of this form MU T 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 determ' a said site' suit abil' fora u d bsorption sewage treatment al system. � , cf L DATE SIGNATURE DCHD'(1193) j c) 'RPPRoY,i;MPT �. ` ROM slTL- 1 G. FR 14 N K D F� e �-,D 1 DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation NAME ��` DATE EVALUATED ADDRESS PROPERTY SIZE PROPOSED FACIILTY LOCATION OF SITE Water Supply: On-Site Well Community Public Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3 4 Landscape position Sloe Z 2 '� HORIZON I DEPTH Texture groupG Consistence Structure Mineralogy HORIZON II DEPTH L _3 X- 1:6 Texture group Consistence Structure 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: . O� 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 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 ■■■■■■■■■■.■.■..■■■..■.■■■■.■■■.■■■..■t...■■.■..■■......■■ ON■■■.■ ........................... ..................................■■■. ■.■■■■■■.■■■■■■M■M■■MMMMM■■■..MMM■■■■■.■�■■■■■■ ■■■■■■■■■■■■■■■■■ ■■■..........■■■■■..■■■■■■■t■M■MM■■■M.■■■■....■■■■■■■■■■.■■■■■MMM■ ■■■■■.■....■■■........■aM.■■.MMM..■■t■.■..■.....■._....■t.■t...■■■ iiiiiiiiiiiiiiiiiiiiiiisiiii�iiiii=iiiiiiiiiiiii■iii'�■iiiii■iiiii=■ ■■■.■....■....■..■..■■....■..■■M�M...ttMM.�...t./..■.MMMMM... ■■■ ■■..MMM■■■MM■.MMMMMO..MMM■11��'..�.�■.■■■■M.ttM■■■■■.M...MMMMM■■t.■ UMENEEMMENNENMEMINIMMUMEMELIMUMMENE mimmom ��:om■"Emmommu ONEENEEM ■■M■■MM.■■M.■■MMM..■■■■....■■MMM.tMM..■■MMM■■■aM M. ■MM..tM■■■M■t■ ■■...■...ttM.■■■MMM.M■MMM.■ttMMMt■M■MM■■aMM■■.■Mt■■tMM■■■ MMM..tM■ ...................................... ..E....... .�■■■■■■■■■■N■■■ ...................................... ...... . .■■■.■■■■.■.■■ ..............■.N■■■■.t..t....M.�tMM.�N.MM.■. ...t.M.N.M .■■■ ■.■■...■.■..MM.ttNNMM.■tMMM..■..■■■Orr_ ■■ ■■�■■�■■ MNNMMC.MMM.■�M ■■■■...■■.■■■■■■■■■■■/:1■. !\■■I/7%LSEX■■■//NEW_ A■■■■■■■■■■■■■■■ ME■■MMM■■MM■■/1■■/■\tit■.■..■.�/ G�C'.�i�■■moi■ ■�`�i ■�`/:C/�H.■■... ........ice........■............. 0 ME in ■■NM MINIMUM . ■ M■MOMM■M■M■M ■■.■t■.■■■.M.t.M■■..■tM■■■■■M■■.�■■■■MN■■■■ ■■■■/■....■■■MONO ■■.■Mn■■MMM■■M■■■■■MMM■■■.■■■■.■■■■ ■■■■ ■ �� M■■■■■■■NMNNMMM■ ....... :RIMEMOMMOMME�_::':_::=�'s:::=::::::::_:m ME :::::::m■■.�■..........................= Z .■� ..............................■!■.MMN�..■�CMM■■■■MMMM■ ■■■N M■M ■.■.N..■■■■.■.M..MM.■.N.■■■.NM■ MMM■.t. t...t11MIl.MM..■■M■■MMM..■ ■...■■.■./Mtt.t..■t■■.■.t■N■■..■.■.■.MM. 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