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VV
DAVIE COUNTY HEALTH DEPARTMENT
a ► '� IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
NTE:Issued in Compliance With Article I I of G.S.Chapter 130a
v' tee' 1?
p Sanitary Sewage Systems.. Permit Number
/ ��f
Name �.r/i /', /% � ��/f i.r's 'J'4 ; 'c , Date��" S� N 0 i-7
026
Locati0 /rj��� /<`/f%l�iiNr"�`' c%�v' /�" 1 {f/ /iii / 6: �� .'i.'.✓`G rid //�_
Subdivision Name Lot No. Sec. or Block No.
Lot Size /f� House Mobile Home t/ Business Speculation
No. Bedrooms No. Baths No. in Family _
Garbage Disposal YES ❑ NO
Specifica ions for,.System:
Auto Dish Washer YES NO ❑ t�
Auto Wash Ma shine YES T NO ❑ j
Type Water Supply __— p�� `✓
'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
"Contact a representative of the Davie County Health Deppa�r�tmentlNbrtfinal inspection of this system between 8:30-
9:30 A.M. or 1:00-1:30 P.M. on day of complet' t.-7ele one Number 704-634-59 5.
Final Installation Diagram: System Irl�ytalled by_
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\�
16G
`"
1601
Ss
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— rt
. 1-1 a
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.
t APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section
P. O. Box 665 �%� ��/l
Mocksville, NC 27028
1. Application/Permit Requested By �/ .•Cex,�. ' " /V�`
Mailing Address'" B"t'r �Go�c3' Z O /�
J � �' G' d 0 G-�R/1 'tiC x.70
Home Phone 2Z2 % l L !� ! 2!�_ — Business Phone 7_.�?
2. Name on Permit if Different than Above
3. Application/Permit for: - -General Evaluation ❑ Septic 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 co
❑ Basement/No Plumbing
No. of Bedrooms 'Washing Machine
No. of Bathrooms 2 _G-Btshwasher
Dwelling Dimensions —=arbage 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: e$PuBlic ❑ Private ❑ Community
8. Property Dimensions T f?0 Sewage Disposal Contractor
9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes ❑ 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:
v C/_
a� d s //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. 7
DATE SIGNATURE
CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY
MUST CHECK ONE: ❑ 1. 1 OWN the property. ❑ 2. 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 Davie County Health Department to enter upon above described
property located in Davie County and owned by
to conduct all testing procedures as necessary to determine said site's s 'tability fora round absorption sewage treatment
and disposal system.
DATE IGNATURE
DCHD(12-90)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
NAME l r�� .� � /% /L/ DATE EVALUATED �O e
ADDRESS v: �''�>` �D / � �� PROPERTY SIZE 0!�_74
PROPOSED FACIILTY N • LOCATION OF SITE _&e2?
Water Supply: On-Site Well Community Public t�
Evaluation By: Auger Boring &--- Pit Cut
FACTORS 1 2 3 4
Landscape position
Slope %. —
HORIZON I DEPTH -y .4t .+
Texture grouz_ S G
Consistence
Structure
Mineralogy
HORIZON II DEPTH
Texture groupG
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: EVALUATED BY:
LANG-TERM ACCEPTAN='T
E: OTHER(S) PRESENT:
REMARKS: e
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
Mineralo6ty
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