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254 Marchmont Dr Lot 22 DAVIE COUNTY HEALTH DEPARTMENT y ` { IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION *NOTE:Issued in Compliance With Article 11 of G.S.Chapter 130a Sanitary Sewage Systems.r Permit er Name Date Location — Subdivision Name Lot No. Sec. or Block No. Lot Size House — Mobile Home ._ Business -- Speculation No. Bedrooms .No. Baths '� No. in Family — Garbage Disposal YES NO ❑ Specifications,for System: Auto Dish Washer YES NO ❑ /QQj�A l /R Auto Wash Ma thine YES NO ❑ "� 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. � l 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 704-6344--598855. — --- ..3 i th. t'i A� ��c► —r— Final Installation Diagram: System Installed by — i � i w C a cc Ld 0 rs Ce lificate of Completion Date 1-> *The signing of this certificate shall ndicate that the system described above has been installed in compliance with the standards set forth in the above gulatic�n, but shall in NO way be taken as a guarantee that the system will function satisfactorily for any given period of t me. t Y ' APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERA 1IT Davie County Health Department Environmental Health Section T P. O. Box 6651 2 6tom�G» Mocksville, NC 27028 ¢�- D V OUNTY HEALTH DEPT. 1. Application/Permit Requested By t� /— Mailing Address .77/,- / �1 1���r�f� Home Phone cglgl 7ti 1 196 •`► Business Phone 2. Name on Permit if Different than Above 5 3. Application/Permit for: ❑ General Evaluation 57'Septic Tank Installation 4. System to Serve: G2'House ❑ Mobile Home ❑ Place of Public Assembly ❑ Business ❑ Industry ❑ Other �j /n1 / ❑ Unknown JAI 5. If house, mobile home: Subdivision k66Z �-kT M, ATj/)7Q)V Section Lot# PXIAN Ta ROW* 44 rt9fi 434asemenUPlumbing No. of People Bpi MEAT 3 ❑ Basement/No Plumbing No. of Bedrooms ❑,,Washin S�J9T'l0/I/ s Machine No. of Bathrooms �jj� yZ dishwasher Dwelling Dimensions 4,0 k,4C5� ��� y � ax�/}7) 9--darbage 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 �J ❑ Private ❑ Community 1 * 8. Property Dimensions 5:,C4—ArT/{ Sewage Disposal Contractor II/VI �4141`,f1f�ww IG fi19/Y�( 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes V/No fX,--Fl i 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: fWKF" PAM(E5 6fi��K ;Y NwY�3g 7"� gel� g�J TO )9 D O S X 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 SIGNATU E CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED ROPERTY Fand ECK ONE: [p 1. I OWN the property. 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 Davie County Health Dep ment to a to po a e described cated in Davie County and owned by A-i E' `,- L all testing procedures as necessary to determine said site's suitability for round absorption sew ge treatment al system. 0,11A6 — 9 , DATE SIGNA RE DCHD(12-90) H r FyS M LL 4`F .:§� - k. a��Q". - f .. _ '• �: pb�i f-.i���V�'i r Z: ..�� - -'3 ` r ' t9 _i t :, a 4 � .r" t ~ •ate .:'s .3 Dd £? 1 t - . . � � .: � f#j��- �3 •jog• � +!!_ �fr r 2 `M '` :-CX�R�•ic..-r6•�- �. ..ww. ��r-r`..c.'U�,v+L_ ca��/. _ _ - �. 3� S? _- �-- _ - _ - ,� i �3 Fe'e� ' �3 CK � . < .. .p Cw►�0.�.i�..t 401_-rr.+4L aM+ti. "� - - _ • �� -Cola1. 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Vv..Cz: N:TGA - t . • 46` r ` DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site`' valuation NAME DATE EVALUATED ADDRESS PROPERTY SIZE QAC PROPOSED FACIILTY Ali f�f LOCATION OF SITE Water Supply: On-Site Well Community Public4--- Evaluation Evaluation By: Auger Boring Pit Cut FACTORS I 2 3 4 Landscape position Slope % — — `— HORIZON I DEPTH Texturegroup S1_ S C c -- Consistence Structure Mineralogy HORIZON II DEPTH1F t- Texture group t77— Consistence Structure i _f v s-'4/t- Mineralogyi ,•i HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION S LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: r� EVALUATED BY: 1-1 LONG-TERM ACCEPTANCE RATE: % '7 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-Film 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 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 ■■.■■■■MIIMIMIMIM■.NIMNMI.■■IM....EMI■■IM..■■■■■.■..■.■■■■■.■■■■■..■■■■■■.■■ ■■■■■■■■■■■■■■■■■■■■.■■■■■■■■■■. ■■■■■.■■■■■■■■■■■.■■■..ter.■■■■■■■ ■■■■■■■n.■■■.■■■■■.r�.■■■■■■■■■■ ■■.■■■.■.■■■■.■...IMr�a■...■■■ ..■ ...............................■......................... ■.■■.MINIM...... ....,..�...;...�......�......�...... 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