178 Laird Rd DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND .CERTIFICATE OF COMPLETION
*
NOTE:Issue in Compliance With Article 11 of G.S.Chapter 130a
Sanitary Sewage Systems Permit Number
Name /�fi'� �. s ...,yai,) // �, :� ✓,,//Date N2
P595Locati
y„
Subdivision Name Lot No. Sec. or Block No.
Lot Size House Mobile Home "'l/ Business Speculation
No. Bedrooms No. Baths—�� No. in Family 11L"_—
Garbage Disposal YES ❑ NO [ Specifications for System:
Auto Dish Washer YES 4 NO ❑
Auto Wash Ma,hine YES ❑ NO ❑
`I
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. .
LJ
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,,'
Certificate of Completion < ���n Date
'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 as a guarantee that the system will function
satisfactorily for any given period of time.
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
a I` Davie County Health Department
Environmental Health Section 1
P. O. Box 665
Mocksville, NC 27028
1. Application/Permit Requested By. �e7
Mailing Address
Home Phone ,y2r'—1-A/ Business Phone
2. Name on Permit if Different than Above
3. Application/Permit for: ❑ General Evaluation 2-5eptic Tank Installation
4. System to Serve: ❑ House Mobile Home ❑ Place of Public Assembly
❑ Business ❑ Industry ❑ Other ❑ Unknown
5. If house, mobile home:Subdivision Section Lot #
❑ Basement/Plumbing
No. of People 'OF ❑ Basement/No Plumbing
No. of Bedrooms ❑ Washing Machine
No. of Bathrooms ❑ Dishwasher
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
A090e of water supply: blic ❑ Private ❑ Community
perty Dimensions ,� �� Sewage Disposal Contractor
you anticipate additions/expansion of the facility this sytem is intended to serve? D Yes ❑ No
If yes, what type?
OTE: 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:
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 appli tizQ
on.
�
DATE SIGNATURE
CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY
F
CHECK ONE: D 1. 1 OWN the property. ❑ 2. 1 DO NOT OWN the property.
hecked Box#2, the rest of this form MUST be completed by the owner or a person authorized by the owner:
y give consent to the authorized representative of the Davie County Health Department to enter upon above described
y located in Davie County and owned by
uct all testing procedures as necessary to determine said site's suitability for a ground absorption sewage treatment
posal system.
DATE SIGNATURE
F
40 DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
NAME DATE EVALUATED
ADDRESS
PROPERTY SIZE
PROPOSED FACIILTY LOCATION OF SITE �s
Water Supply: On-Site Well Community Public -�
Evaluation By: Auger Boring Pit Cut
FACTORS 1 2 3 4
Landscape Rosition
Slope Z
HORIZON I DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH
Texture group C
Consistence 7 f
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:
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-Finn 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
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