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298 Brantley Farm Rd 1/ 30 - 'DAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION -'NOTE:'Issued in Compliance With Article II o G.S.Chapter 130a Sanitary Sewage Systems nPermit Number Name �. �. \ 4 `,.t� :;�� ;\>> \� Date V � � N2 7901 Location Subdivision Name Lot No. Sec. or Block No. Lot Size House — Mobile Home _v-- Business -- Industry No. Bedrooms -?_.No. Baths —= — No. in Family — Public Assembly Other Garbage Disposal YES ❑ NO J Specifications for System: , 4 Auto Dish Washer YES ❑ NO M-' Auto Wash Ma^hine YES EJ- NO ❑ 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 or the intended use change l . ATTENTION: YOUR SEPTIC SYSTEM CONTRACTOR MUST SEE THIS PERMITILAYOUT BEFORE INSTALLING 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., 1:00-1:30 P.M.or 4:30-5:00 P.M.on day of completion.Telephone Number: 70.4-634-698&,g`/6-0 Final Installation Diagram: System Installed by F T Fu A/ i Certificate of Completion _ o _ Date - 5_ '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 given period of time. 11 APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PER RETCEy E Davie County Health Department Environmental Health Section FEB 2 p 1995 P. O. Box 665 Mocksville, NC 27028 th 1. Application/Permit Requested By P, Mailing Address as CD '� Home Phone (c 3�� _ 7 S� '-I Business Phone la 7(A 0�d K LI 2. Name on Permit if Different than Above LL 3. Application for: d General Evaluation W'Septic Tank Installation Permit 4. System to Serve: ❑ House GYI(Aobile Home ❑ Place of Public Assembly ❑ Business ❑ Industry ❑ Other ❑ Unknown 5. If house, mobile home: Subdivision Section Lot # ❑ Basement/Plumbing No. of People ❑ Basement/No Plumbing No. of Bedrooms (BOWashing Machine No. of Bathrooms a fU Dishwasher Dwelling Dimensions ❑ Garbage Disposal 6. If business, industry, place of public sembly, 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 �We. Po rivate ❑ Community 8. Property Dimensions _;70 -1 8 'Se'wage 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: t�;k kQL- Poic�c9� a tr, ��.�. Cuss 4L�k qv�lykk s V V' �u`l u� • W CU V-1 r S �J` �.w�� `�D Q.�.c,�t C� W o a cis 1 n V ,r 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 ap ication. il t7 I q,�— 4-� ATE SIGNATURE CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY Fand ECK ONE: Q�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 representat' epf the Dayie Co ty Ith Deparlap�t to enter upon above described cated in Davie County and owned by /lam "f �LL�\?? all testing procedures as necessary to c to mine said site's suitability for a group absorption sewage treatment al ystem. DATE SIGNATURE o� DCHD'(1193) d +' * DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section ' Soil/Site Evaluation r� ^� c� NAME \v\ Q:�.�� b� Q�� DATE EVALUATED '1 --� 1 - L S ADDRESSPROPERTY SIZE PROPOSED FACIILTY Vo ccc,� LOCATION OF SITE Water Supply: On-Site Well y _ Communit/� Public Evaluation Bye. N, Auger Boring Pit t/ Cut FACTORS 1 2 3 4 Landscape position S -S S Slope Z o - 0-F ` Ec HORIZON I DEPTH fill al' Texture groupL lr L Consistence FS Structure C Mineralogy 1 1 1 1 HORIZON II DEPTH 3 G 3 ` Texture group L° Consistence EL Structure Mineralogy HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON — SAPROLITE — — CLASSIFICATION S LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: ('�' • EVALUATED BY: LONG-TERM ACCEPTANCE RATE: OTHER(S) PRESENT: \Zo a 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-Vf---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/ftz DCHD(01-901 --u9 ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■�■■■■■■■■ ME■■■■■ ................................■......... ........ .■■■■■■.■■■■. .■.................................................. ■■■■■.■M■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■ ■ 0 ONE Emonomm EN iiiiiiiiiiiiiiiiiiiiiiiiiiiii'iiiii'i�i.Hi■iiii=i iii� dmm'iiii0 1� :__ .......uo■■■■mmm■■■o■■um■m■■■■�omm■■n■I■m�.m.i\A■IN►..,.►.......�■■■ mommommi mommlm&mmmmm NMI mommomm No MEMO 0 ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■N■ii■■■■mCa■w■01 ■!■■mmol ■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■N!! ■ ■■o■o■■■■■■i MMCMENEM ■■■■■■■■■.N■■■■■■■■■■H■■� ONESEN ON ■■■■■ml■■■■■ ��\y M mm■m■■■■ ■■■■■■■■■■■■■■■■■■■■■■■mH■■■■■mqmmmmmmm oll■■■ ■■■■■■■■■■■NN■■■■■■■■■■■■H■■■■.I1 ■N a�n NEEM■■■■ iiiiii'mCiiii��uiiiiii�i■�=iu MINE mommommi i'■'�i' w_ ■■0 MEMO moomoommll"r li=m=MERE momimom ■■ 6 ■EME EH'.■E'N 0 =NOME 1111M mmoommi ■NMN■NNS%•EE'E!i!'�'i■■■\1■■■NMN■■n■ '!■ H■■■■■■ MENNEMENSON monomm ■mm■■mm ■■■ ■■■■■■ ■■■ ■■Nmom on ■■mon■■ ■■i�.iiii��=1u.■■■...Nm■ ■■� ■ ■H ■ Room ii■iE'i ' 'ii�i"ii ■■■■■■■■■■■■n■■!:mum.■nl\m■■.E■m� ■��. ■ �■ ■EMEN■■■Noom■ ■■ m■mN. 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