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1591 Peoples Creek Rd Lot 6 '1 -iS'+� O�R1Cw;1a'S'ti^1r't'�i,c�.`K2'r,;'.Y:+sur.'''fi.:^tti.n: F�,�i'd F S' '-'"`"C��;" .w i' ,✓r-. r ..x +> - - �y``+.' x;' ]f�h;s�.t[Y'i 6('rt .t` +; -k i ►� f \Mi;....:..+; '\±\\` �� !/i i 7/ ''DAVIkUNTY HEALTH DEPARTMENT ,Y • IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION *NOTE:Issued in Compliance With Article 11 of cc S.Chapter 130a Sanitary Sewage Systems Ilwe Permit Number Name�—t2 l.Li driS a�7/D� D/atte � "/—ZAV S� N27843 , Location e-D1� Subdivision Name �/9/ �' Lot No. Sec. or Block No. _ LotSize �r�ouse—o��- Mobile Home _Y Business -- Industry No. Bedrooms 1-0/1No. Baths /a No. in Family _ Public Assembly Other Garbage Disposal YES p NO Specifications for System: Auto Dish Washer YES NO Auto Wash Ma^hine YES g NO p Type .Water Supply *This permit Void if sewage system described below is not irrialled within 5 years from date of issue. This permit is subject to revocation if site plans or the inte d u e change. _ Iz hnc Improvements per it by /7u` *Contact a representative of the Davie County Health Department for final ' pecti of is ystem between 8:30-9:30 A.M., 1:00-1:30 P.M.or 4:30-5:00 P.M.on day of completion jelephond Nu r.70 34- 85 / 'b '0 Final Installation Diagram: to I nsta d by — �� J le Certificate of Completion 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 taken as a guarantee that the system will function satisfactorily for any given period of time. - � APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT p�� s Davie County Health Department R E C E o V E D Environmental Health Section 1993 P.0.Box 665 JAU Mocksville, NC 27028 1. Application/Permit Requested By/� - Mailing Address /7--251 P/0 Cc-�9�i,�0 Z4,12 S- �N s/0 -�$�r��r'a , N•e .i!7103 Home Phone C%�O� 760-63v2 9 Business Phone 2. Name on Permit if Different than Above 3. Application/Permit for: � ❑ General Evaluation Z Septic Tank Installation 2" House System to Serve: 27 House ❑ Mobile Home ❑ Place of Public Assembly ❑ Business ❑ Industry ❑ Other ❑ Unknown 5. If house, mobile home:Subdivision /Z�VM/Z limy XGr{5 , A14VYVCE Section Lot # 6 R(BasementlPlumbing No.of People 5 -6 ❑ Basement/No Plumbing No.of Bedroomslashing Machine No.of Bathrooms ' S 0/WDishwasher Dwelling Dimensions y� �X �0 6t ��aiy�,. ❑ 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: Vpublic ❑ Private ❑ Community 8. Property Dimensions -5EA A1.4 Sewage Disposal Contractor Thi A 9. Do you anticipate additions/expansion of the facility this sytem Is intended to serve? ❑ Yes [?I�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: F4191" ` moo/ S F-K' 4 Xv7L �6 ��ojo-le.s Cy'r ►7+ etz rvrma/Cc sv/ . V / t 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 application. DATE Si NATURE CONSENT FM SITE EVALUATION TO BE DONE ON ABOVE pESCRIBED PROPERTY Fandd ECK ONE: V1. I OWN the property.1)%re�,rsmg ❑ 2. 1 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 Dpvie Coun�ty Health Depar�ment to nter upon above described cated in Davie County and owned by.STe4rge, �9,w¢.9 STE.,ie V/Aluc�/lset^s all testing procedures as necessary to determine sai site's suitability for a ground absorption sewage treatment als tem. DAT SIGNATURE DCHD(12.90) Je) Ac Lot k ` S► �7 �` r 51!'' y c`nC.� A ties Io 6e KJACJ 40 Lo eQues�' Sep�`c, PieICI L i r1e-5 4o be Loc6Jetd �o 10 —V�1e Fr.o4 of Horne- 'S I'A ome,'SiA2 O+L 4-o ,�cic House AWaLA fp-Oy-vA Ca"' e, Ow.ne 2,5 W u 4 `I-o -REserev e -RQa.(�) L,arj space or 1= du f ep- of Pool ' DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation NAME ��� /� DATE EVALUATED ADDRESS PROPERTY SIZE PROPOSED FACIILTY l'� LOCATION OF SITE Water Supply: On-Site Well Community Public Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3 4 Landscape position ,L Sloe % Z HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH 7' 77 7 3l a <i Texture group C2 Consistence 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: O� 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 ■■■■■■■■■■■■■■■.■■■■■■■■■■■■■■■■■■■■■M■.■■■/.■■■.■.■.iii.■■■■■■.■■ ■■..■.■..■...■■...■■.■..■■..■.. ....■■...■..■..■■.■■..■.■■■...■■ iiiiiiiiiiiiiiiiiiiiiii■si�■iiiiiii=iiiiiiiiiiiiiiii iiiiiiiiiii=� iiiiiii■iiiiiiiiiiiiiiiii�iiiiii�iMEMEMEiii�iiii.iiiiiiiiiiii■i=mom .................................................. ..■....■...■... ........■...■...■.......■.......................■.......■......... ................................ ................................ 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APPLICATION FOR SITE EVAUlA110N/IMPR0VE1AENT PERMIT do ATC Davie County Health Department Environmental Health 5LcffOn P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)7S1-8760 ***XWCRTANT*** THIS APPLICATION CAMOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 1. Name to be Billed e6LiAi9LC- U(L.D6-g'- 1NC. Contact Person -JE-FF 1-19 ml e' Mailing Add.... -AA-4- W67- 4rh JT Home Phone 7,93-/56P2 City/State/ZIP Wi N S'T41V- S/a L6m NC-- 2711 Business phone 414-7,3133 2. Name on Permit/ATC If Different than Above JOE WOQ5lE� Mailing Address 148 D U f W ooD Pitt `i 2C i E City/state/Zip `j'U Pc L00 M i SS i ss I PP 1 388o 3. Application For: Site Evaluation 0 Improvement Permit/ATC 11 Both 4. Systea to service: 1 House 0 Mobile Home 0 Business 0 Industry 0 Other 5. If Residence: # People 2 # Bedrooms 3 # Bathrooms 2 5 p Dishwasher Ji Garbage Disposal YiVashing Machine O Basement/Plumbing 0 Basement/No Plumbing 6. If Business/Industry/other: Specify type # People # sinks # Commodes # shovers # Urinals # Nater Coolers IS FOODSERVICE: # Seats Estimated Nater Usage (gallons per day) 7. Type of water supply: /P(County/City 0 Well 0 Community a. Do you anticipate additions or expansions of the facility this system Is intended to serve! 0 Yes 1VNo If yes,what type. ***IMPORTANT'**CLIENTS AIUSTt:OAfPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PIAT or SITE PLAN AIUST RESUBMITTED by the client with THIS APPLICATION. Property Dimensions: 3. (f 2 ACXC--S WRITE DIRECTIONS(from MockrAlle)to PROPERTY: Tai Office PIN: # 158 Ty 801 s To Property Address: Road Name 159 T 0oPl N &CCK S a6ex P06D City/ZIP 4DV4WC1CN.e, ,�OUO(p TyeN LEFT Go 7y If in a Subdivision provide Information,as follows: Car 1 s oN 2i GN'r Name: 111a2C(4 �E2(Z We2Es Section: Block: Lot: ( Date Property Flagged: This is to certify that the information provided is correct to the best of my knowledge. I understand that any permit(s) issued hereafter are subject to suspension or revocation,if the site pians or Intended use change,or If the information submitted in this application is falsified or changed I,also,understand that I am responsiblefor all charges Incurred from this applicaadom I,hereby,give consent to the Authorized Representative of the Davie County Health Department to enter upon above described property located in Davie County and owned by :Toc- W o,-s L6Y to conduct all testing procedures as necessary to determine the 2subility. ;�� "I DATE 1G'v��9 SIGNATUR . /THIS AREA MAY BE USED FOR DRAWING YOUR SITE Pa all of the following: Existing and proposed property lines and dimensions, structures, setbacks, and septic locations). Account No. Revised DCHD(07/98) Invoice No. r . DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section 11 Soil/Site Evaluation NAME O 7� DATE EVALUATED ��/ ADDRESS sr�/F �r� PROPERTY SIZEIV �o / PROPOSED FACIILTY /y��' LOCATION OF SITE I'7 91a Water Supply: On-Site Well Community Public Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3 4 Landscape position 4 L L Slope ,:Z- HORIZON HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH y Texture group Consistence Structure JAle Mineralogy /• l•/ %- %�/ HORIZON III DEPTH Texture group Consistence - Structure Mineralogy 7 HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE , 3 SITE CLASSIFICATION: Jr. EVALUATED BY: A"Z 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-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 Mineraloey 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 watef 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 ........................... ..........................■.■......... .................................................................. ■■■....u..■■■....■■■■■■■■.■■■■■� ■■■■■■■...■.■..■.■■......... ■■. 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