1037 Liberty Church Rd �PF
DAVIE COUNTY HEALTH DEPARTMENT '
5 -=`✓ �y IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION .
M
NOTE:Issued in Compliance With Article 11 of G.S.Chapter 130a
/_ „ Sanitary Sewage Systems Permit Number
Name 1 �/, ���7 �.�1 i1 Date . '',�,�/ N2 7486
Location `�-
,�.Xbe- C)1-vt rc%_7�d - TOA7
Subdivision Name Lot No. Sec. or Block No.
Lot Size ! ��—House �'""�� Mobile Home _ Business -- Industry
No. Bedrooms _,J No. Baths e� — No. in Family Public Assembly Other
Garbage Disposal.. YES ❑ NO ❑ Specifications for System:
Auto Dish Washer YES CJ NO ❑
Auto Wash Ma^hine YES e NO ❑ V ✓ '.
Type Water Supply _ P// --- ���jt, h�✓� N
*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.
_4
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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:704634-5985.
Final Installation Diagram: System Installed by a, �*«��►�= �.�M.Ar
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t!�`r
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Certificate of Completion Date (, -12 -
'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.
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department FEF 0 V, E D
Environmental Health Section
P. O. Box 665 4 1994
Mocksville, NC 27028
1. Application/Permit Requested By11 800E ?!JAR L K '
Mailing Address. ! 3 3 7 NILTlnexE z)2 Home Phone 70, —53+`-93'¢'1
21-0 77-4 �, 28 2 0 -7 Business Phone
2. Name on Permit if Different than Above
3. Application for: a General Evaluation IrSeptic Tank Installation Permit
4. System to Serve: VHouse ❑ Mobile 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 ❑ Washing Machine
No. of Bathrooms ❑ Dishwasher
Dwelling Dimensions X Z7 ❑ 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 U 6ge Figures
7. Type of water supply: ❑ Public Private ❑ Community
8. Property Dimensions �S� �°� A Sewage Disposal Contractor
9. Do you anticipate additions/expansion ol the facility this sytem is intended to serve? Yes ❑ No
AJ
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: %�[.� / O1/yIg
2, 2-
/n rn GUa
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 fromthi /ppli tion.
: - !
t 2"
DATE IG TU
CONSENT FOR SITE EVALUATION TO BE DONE ONBA OVE DESCRIBED PROPERTY
MUST CHECK ONE: ❑ 1. I OWN the property. 72. 1 DO NOT OWN the property.
If you checked Box#2, the rest of this form MUST be completed by the owner or a person authorized by the owner:
I hereby give consent to the authorized representative of the vie County Heal Department t enter pon above described
property located in Davie County and owned by .(2(,,,
to conduct all testing procedures as necessary to determine said site's suitability for a ground absorption' swage treatment
and disposal system.
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DATE SIGN" E
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' DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
• Soil/Site Evaluation
NAME A/'lE�c� DATE EVALUATED
ADDRESS PROPERTY SIZE
PROPOSED FACIILTY , 15�e' LOCATION OF SITE
Water Supply: On-Site Well J'� Community Public
Evaluation By: Auger Boring t/ Pit Cut
FACTORS 1 2 3 4
Landscape position L �,
Slope
HORIZON I DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH -f r 3 -f'
Texture group
.Consistence
Structure
Mineralogy /y 14-1
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: AG
LONG-TERM ACCEPTANCE RATE: "T OTHER(S) PRESENT:
REMARKS:
LEGEND
Landscape Position
R-Ridge S7-Shoulder L-Linear slope FS-Footslope 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
5C-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
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