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1546 Bear Creek Church Rd j c.., ..., •rp w. t57 Ri;wly` � 'y s6, biA I Ips 'y^; DAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION *NOTE:Issued in Compliance With Article 11 of G.S.Chapter 130a 'Sanitary Sewage Systems \ `\ .�– Permit Number Name 110 W e�� e��t N'P. W s Date " 214 NO t 4 6 3 Location Subdivissi&Nme Lot No. Sec. or Block No. Lot Size " °House Mobite Home —� Business,__ Industry R No. Bedrooms �Vo. Baths No. in Family _ Public Assembly Other Garbage Disposal YES--E] NO�'Pll " Specifications for System: , Auto Dish Washer'`iYES' NO,❑ /pUo o•p ;:� 1� a- Auto Wash Ma^hirie YES []y N0 ❑ 3 v, k "� k ) �ti� 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 d"r•the intended(�uj�se arige. �1 y 4 i w AIM, T 0 0 o 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 corppletion.Telephone Number:704-634-5985. F„ Final Installation Diagram: System Installed by � *�- W o � o ilk Certificate of Completion Date 'The signing of this certificat sh in icate 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 PERMIT Davie County Health Department Environmental Health Section lit— P. I� r,�. t�, P. O. Box 665 [I CIE I: `�� 11 LDMocksville, NC 27028 1. Application/Permit Requested By / S - - -- - - -- Mailing Address�Q' 3 O/3� ��C� Home Phone 6 43,-S7 Business Phone 2. Name on Permit if Different than Above 3. Application for: a General Evaluation Urge-ptic Tank Installation Permit, 4. System to Serve: 2rHouse ❑ Mobile Home ❑ Place of Public Assembly ❑ Business ❑ Industry ❑ Other ❑ Unknown 5. If house, mobile home: Subdivision Section Lot # a-f-asement/Plumbing No. of People ❑ Basement/No Plumbing No. of Bedrooms 3 10�Washing Machine No. of Bathrooms r? 1/0 -0-15-ishwasher Dwelling Dimensions ❑ 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 zlrlvate ❑ Community 8. Property Dimensions q q Sewage Disposal Contractor 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes .12- o 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: 6o / "To&-7QPd %lAol�Ci,tlU. 11�' �� off j Ckmc-lam 2c,. L oll OlicEc , 9. s - 3 m,'k-S ON TDISI4- C I)qS-r o c f-- l"0W6 cOv/u T bD 10 ui/ 2,'d 12c d 1.'11 6 i?o,V T-. 14ousc- (ocA-rcd `I N �-)raoul �a' c9 L00c7c)S 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 fr m this application. DATE SIGNATURE FanddCONSENT OR SITE EVALUATION TO BE DONE-N ABOVE DESCRIBED PROPERTY ' ECK ONE: ❑ 1. I OWN the property. r0' 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 County Health Department to enter upon above described cated in Davie County and owned by /e741�/ / , & 9F<7- all testing procedures as necessary to determine said site's suitability for a ground absorption sewage treatment I syst7e . l DATE SIGNATURE DCHD'(1193) ` DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation i NAME bb W ear�1 N `�es�C DATE EVALUATED + - ADDRESS a PROPERTY SIZE W PROPOSED FACIILTY `A a LOCATION OF SITES Ra Water Supply: On-Site Well Community Public Evaluation Byk't, . Auger Boring Pit Cut FACTORS 1 2 3 4 Landscape position S S _r Z Sloe Z a 75-- - t1 HORIZON I DEPTH Texture group L_ L Q L C Consistence FZ F'Z Structure T ' Mineralogy HORIZON II DEPTH 4Di' 4*A �. Texture grouQ-4 Consistence FT y�L Structure Q PO );�k Mineralogy HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS Ss RESTRICTIVE HORIZON -- SAPROLITE — — CLASSIFICATION LONG-TERM ACCEPTANCE RAT E , SITE CLASSIFICATION: ` S ' EVALUATED BY: LONG-TERM ACCEPTANCE RATE: OTHER(S) PRESENT: REMARKS: C VA14 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 l:lay 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 ■■.■■.■■■■■■■■■■■■.■■■■■■■■...■.■..■■■■■■■/■.■■■■■■■■■■■■■ ■■■■■@■ iiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiii■iiii��iiif'�g�iiiiiiNii ■■■■■■■■■■■■■■■■■■■■■■■■■.B■..■■■■ ■■■■■■■■■■n■■��■►\■��■■■■■■■■■.■ ■.■..■■....■i.■■■■..■...■...■...�..■.i.■■■�■.■■■.■11■I■■■■■■■■■ ■■■ MEMEN M ■■.■■■■■.■■■■i.■.i.■..i.■.......�■■..■■■��II�B��uJ■■iii.■■■■■■■■ MENNii�iiiiii�i■iiiiiiiiit■MUMMEME �Will 0 MEMNON� ■■■■■■■■■■■■■■■■■■■B■■■■■■■■B■■■■1/[i..B■..■■■�� B■�IBB■■■■■■■■■■■■ ■■■■■■■■■■■■n■■■■■■■■B■■■■■■■BB■iiriR1B■inB�■ENEM■B �RRIUK7■■ ■■rim""■ ■■■■■.■■■■■■■iii■i■■.■■■■■..■■■■.■■r��.■ ON ■II■■■■ F/1�if1■■■■■■■t1►.�rull(il■ ■■■■■■■■■■■■■■....■■.....■■.i....■\AL./. ■■■■■ 'ICI\�J■.■■■.■�:r■`i',. ...........8■■uBB■■■■B■■■■■■■■■■■■w:■ ■ on awC■I■■■I1=■■■■■■1� ■■■/...��I.i.N■.■■.■■■i.■■■■.■i.� ■■■■ NONE ■i ■ ■■ .■■■■■■■■1/�■■■/■.!1■■■■■■■■.■■■■.■■■■■i ■■■ N■■■■H ■■■■■■■u■■ ■■■■ ■■■It■B■■■■■11■■■■■■■■■■■■■■■■■■■■■.■■■■ .�.■■■■ ■■B■■■■B■■■m■■■■ ■■■It.117r■!�!■■Llii■■■■■■■■Hi■■■■■B■■■■ ■■B■■H■ ■ ■ ■■■■■■■ ■■■■■■ ■ .......iU■■■1■■■■■■■■■■■■■■■■■■■■■■■�■■■■■■n�0B 1 ■n■�■B■■■■■■■■■ ■■■■■■■■■■■■IBB■■■■B■■■■■■.■■■■B■.■..■■..BBB ■ ■■ ■ ■ ■ H■■■■■■ ■■■■■B��■■■■■I■■■■■■■B■eB■■B■■■B■■BB=ii■iU'B�SOMB =i��i■■iiiiiiii■ ■■.■.■urew.■i■i■.■■......■.■...■■ ■■■■■■iV11'll■■I■■■■■ ■■i■i■■■■■■.■.�■■■■■H■■ SUMMMEMMEM ME ■■ ■■■■ii■■■■■■i■■■■ BB ■B■n■BBB■■■..■■■■■ iiiiMon ii► iiiiii■mo�iiiiiii■i�iii■�iii�iiiiB■ mom n■■■■iiiiu:i■i■�ii ■■■I■■i■■■■illi■■■■■■■■■■■■■■■■■.i■■■■■iHB■■ �■ ■■ ■■■B ■■■■■■■■■■ ..��.N....■.n■■■....■.....■■..... ■.■■■■■ .■■■■u■......■.■.■■.... ■■I(Ai■�■■■.■■i.■■■■■.■..■■■N..■■■■■■■■■■■ ■/■i NOON.■.■■B NOON■i■■ ■.■.■.■N.ii■■ii■.i...... i..■■..■.■.NN .n■ B.■.■■.■.■ ■■N■■B■ .................... ............................................. ................................ .B■■■■■■■■■■■MOM■■■■■i■■■■■.■■■■ .................................................................. ■.■■ ■.■...■..■.......■...■..■.. ■■■...■...■...■■.i..■■■.■■N■■■■ IEEE SEEMS