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P7300 Knoll Crest Rd``.. ,i r. .�.R.uv{S?_4•st _{:�... ...:.-. -,t -.yam:..L^- ,.,a.�'ke } _ r•-E' ,v_rsV' ,, :•\" -_ .. .- ...4. . -. _ _' ',t o ..f_•v:.. DAVIE COUNTY HEALTH" DEPARTMENT IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION 'NOTE:Issued in Compliance With V�iI I o .,S.Ctpapter 30a . mfr 4Permi u er Nam anitary-Sew ge Systems. J/j�i � �:U. �,��1/ ��/.�i:,✓rc� Date e _ 0! r��y; �� ,j J'�^ •` <c';.i�. �ir^i. . 1 i` asp.' /7�.I�/ �/ .r Location Subdivision Name Lot No. Sec. or Block No. Lot Size House — Mobile Home . Business __ Speculation No. Bedrooms .No. Baths No. in Family Garbage Disposal YES NO p Specifications for System: Auto Dish Washer YES NO ❑ /l%�'L%i - ` Auto Wash Ma shine YES 111�� NO Type Water Supply y '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. i 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. or 1:00-1:30 P.M. on day of completion. Telephone Number 704-634-5985. Final Installation Diagram: System Installed by `� r I 'V 1 t 9�u 1 OV �-LFN �j n c .y ,Certificate of Completion 1�3' 17A3Date '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. w • DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation NAME DATE EVALUATED ADDRESS PROPERTY SIZE •SSG' PROPOSED FACIILTY ��` LOCATION OF SITE }i/70// Water Supply: On-Site Well le ' Community Public Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3 4 Landscape position Sloe % HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH Texture group C, c, rC Consistence Structure r v T Mineralogyi 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: /Q C� LONG-TERM ACCEPTANCE RATE: 7 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-Fier► VFI-Very firm EFI-Extremely fine 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 ■.■.■/■..■......■.....■........■ ■.....■.........■.■..■...■■...■■ ■■■■■■■.■/■■■■■■■■■■■.■/■■■■■.■NEW ■■■■■.■.e■■e1■■■■Mee■■■.■■i■■■■■ ■■■■■■■■■.■■■■■■■E■■■e■■■■■■■.■■■e■■■■■■■■■e■■■■■a�i■■■■■■■■■■■M■■ ■■e..M.............r■ciao■.■i■.■..°�.■.■...e..n...ie=....i■■■....■ iiiiiiii■iiiiiiiiiiEiiii■iiiiiiiii�iiiiiiiii�iiiaiiii�iiiiiiii■iiiii ■.■■.■.■.■.■.■.Iii■■e■■■■■../MOEOMMM::iE.il/.O.►\.■MONO momm .■.■.■■■ ■■.■e■.■..■.■.■��.■.■.■.■■■erg./.s...■■■.■I,■■■.■e■e■i.■.■��■�■■■■■■■ ■■.■..t.....■■■i�......e...■.....fit.■.■...■■i.■�H■e■.e.ei■.■.e.e.■ ��■iiii�iiiiiii�iiiiii�i�ii�i�iiiiii��■iiii iiiii��■iiii� ...............■.,..................... _...■.. . ...■. .■■■.... ..................\.............. .... 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N/.■ ■.....■...■....■..EEE■■.■.■ .E■■■E..■■.■..E■.....■■.■.N.■E■ APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT /e? Davie County Health Department Environmental Health Section P. O. Box 665 Mocksville, NC 27028 1. Application/Permit Re sted By. Mailing Address Home Phone Business Phone UU 2. Name on Permit if Different than Above 3. Application/Permit for: ❑ General Evaluation eptic Tank Installation 4. System to Serve: ❑ House obile Home ❑ Place of Public Assembly ❑ Business ❑ Industry "" „❑ Other El Unknown 5. If house, mobile home: Subdivision h�rQ- �n—724Y j a Tr)q cT-*l Section Lot# ❑ Basement/Plumbing No. of People ❑ Basement/No Plumbing No. of Bedrooms Washing Machine No. of Bathrooms p 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 �Ze ❑ Community 8. Property Dimensions SAC elOr� -F2J-XSH Sewage Disposal Contractor 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes C5'IVo 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 Octo Directions to Property: (v,11ON KNo , �CrI6 V Ff , 3� SA r a Ct 0� This is to certify that the information provided is correct to the b st of my knowledge, and I understand I am responsible for all charges incurred from this application. DATE SIGNATURE CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY Fandd ECK ONE: ❑ 1. 1 OWN the property. 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 representatiye�of the D ie C unt Health D partment to enter upon above described cated in Davie County and owned by all testing procedures as necessary to deter a said site's suitability for a ground absorption sewage treatment al system. /3-- Z3 DATE "`--&GFJAT0RV DCHD(12-90) 1 ` Y '44, ; �L ti. N,• �rfi,,n}i ... j'. �•y,. ',y] I low vi Aff 4p, 4s„i Am y n 1 1 � . .{:r. r � x'? ' 'Kra y '' + � h• 3r It 7 i 4