1100 Hwy 801N (2) m -- - DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NO E:Issued in Compliance With Article 11 of G.S.Chapter 1,30a
Sanitary Sewage Systems Permit Number
Name ; ���ti #��� �, ' ��acs Date - C N2 5959
Location 's " `
`'a
Subdivision Name Lot No. Sec. or Block No.
Lot Size House Mobile Home _ Business V Speculation
No. Bedrooms �No. Baths No. in Family" —
Garbage Disposal YES ❑ NO p�- Specifications for System:
Auto Dish Washer YES ❑ NO [0''' / or)
Auto Wash Machine YES ❑ NO
Type Water Supply «� 'S'< --- X
*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.
Improvements permit by %Asa � °�` *' •
*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 �// --, _
r120
1 co x3 X 191'
Certificate of Completion lz/�— 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.
9-� c�
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APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health DepartmentC /0
Environmental Health Section , 0 O
` P. 0. Sox 665
Mockaville, NC 27028
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1 . Application/Permit Requested By s �D SCoc�C 132J -Z-
Mailing Address �� k I �(�cJon c e /j/. ( . V 7 OC)(o
Home Phone 12-74 IV Business Phone 31T- 6 0 0 (
2. Name on Permit if Different than Above J(-r C-k U a 14 v "`-
3. Property Owner if Different than Above KV,r- 4,6:e -1- 14�s-,1
4. Application/Permit For: 0 General Evaluation S/Tank Installation
5. System to Serve: House u Mobile Home Business
0 Industry u Other 0 Unknown
6. If house, mobile home: Subdivision Sec. Lot#
No. of People Dwelling Dimensions
No. of Bedrooms Basement/Plumbing
. No. of Bathrooms Basement/No Plumbing
Washing Machine J Dishwasher 0 Garbage D::sposal
7. If business, industry, 7 `
other: Specify type /X1/HG� `� c �J k.
No. of People Serves'A No. of Sinks
No. of Commodes (,)-- No. of Urinals
No. of Lavatories No. of Westar Coolers
No. of Showers
S. Type of water supply : (Public 0 Private Community
9. Property Dimensions 1 lgcit �-
10. Sewage Disposal Contractor r,`2/��l `�A
11 . Do you anticipate additions/expansions of the facility this system is
intended to serve? 0 Yes oq�o
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.
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 apple ation.
i -74nt-
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Date Signature
Directions to Property :
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DCHD (10-89) `� %
DAVIE COUNTY HEALTH DEPARTMENT
ENVIRONMENTAL HEALTH SECTION
SITE EVALUATION CONSENT FORM
1. Complete the form below and return to the Davie County Health Department.
2. Carefully follow the procedures as outlined in the enclosed "Information Bulletin."
NOTE: THE ABOVE MUST BE COMPLETED BEFORE A SANITARIAN WILL BE ABLE TO
BEGIN THE REQUESTED EVALUATION.
DETACH HERE AND RETURN TO: Davie County Health Department, Environmental
Health Section, P. 0. Box 665, Mocksville, N.C. 27028
Davie County Health Department
Environmental Health Section
Site Evaluation Consent Form
LOCATION OF PROPERTY: DATE RECEIVED
(office use only)
GJ
101 �.+�; o G
yes no 1. I am the owner of the above described property.
yes no 2. 1 am not the owner of the above described property, however, I certify that I
have consent from , owner to obtain a
owner's name
site evaluation by the Davie County Health Department for the purpose of
determining the suitability for a ground absorption sewage treatment and
disposal system.
yes no 3. 1 hereby give consent to the authorized representative of the Davie County
Health Department to enter upon the above described propertyand conduct all
testing procedures as necessary to determine its suitability for a ground
absorption sewage treatment and disposal system.
1
DATI= SIGNATURE
4. 1 hereby authorize the Davie County Health Department to release site
evaluation results from the above described property to the following:
Owner only
— Owners designated representative
Anyone requesting results
-IL�--Only those listed below 1
S.S C-0
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OAi4a�6z
7 90
DATE SIGNATURE
DCHD(11/84)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
NAME R c t" 13 DATE EVALUATED V
ADDRESS S A V\IQ, PMOPERTY SIZE
PROPOSED FACIILTY Nl)'% -\V,Xy S IN° Q LOCATION OF SITE 7f 0
Water Supply: On-Site Well Community Public
Evaluation By: C t.`AugerBoring Pit Cut
FACTORS 1 2 3 4
Landscape position
Slope 7. C, �—
HORIZON I DEPTH
.Texture group33MV
Consistence F r
Structure Ai_-
Mineralogy : 1 1= 1 1
HORIZON II DEPTH lio I
Texture groupl V A/ D
Consistence F' 19
Structure A A
Mineralogy
HORIZON III DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON <-
SAPROLITE .r-
CLASSIFICATION (,S
LONG-TERM ACCEPTANCE RATE Cr �-
SITE CLASSIFICATION: `� , EVALUATED BY:
LONG-TERM ACCEPTANCE RATE: �� _ 1 �� _OTHER(S) PRESENT:
REMARKS: .4`
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
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