289 Marchmont Dr Lot 3 '. DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION 10'3
*NOTEAssued in Compliance With Article I I of G.S.Chapter 130a 0-
-Sanitary Sewage Systems I ' Permit Number
Name �-� �.�� ����?-> 'S UJ\F� Date — ~ U ` N2
6583
Location �• �� } �'''� I�•� —
�`' 1- ' -•tel-\, Qc� � C � -s � ���t>. ����� � 4 `�;����� l,` �,`'�„ \�. , .�1��tcr:ct� -
Subdivision Name Lot No. Sec. or Block No.
Lot Size 5 House ✓ Mobile Home _ Business _— Speculation
No. Bedrooms ' No. Baths 3 No. in Family H __
Garbage Disposal YES ❑ NO Specifications for System:
Auto Dish Washer YES pl NO ❑ /vv 0 c>,a� ���s � �•
Auto Wash Ma:hive YES d 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.
U � S -q
"C
aU i
L s av i
Improvements permit byQ:!S,, �
*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
yd � s �
V�
I
i c'-
Certificate of Completion : E� Date t 2
'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. 5�Y/
_ \ V -
DAVIE COUNTY HEALTH DEPARTMENT
L - t IMPROVEMENTS PERMIT-AND .CERTIFICATE OF COMPLETION ,10 "30
*NOTE:Issued in Compliance With Article II of G.S.Chapter 13oa °�
1 Sanitary Sewage Systems Permit Number
Name V > ��\ �� c�\v Date �� a NO
5 8-3
Location
Subdivision Name �' �'��`���� � +rte'vl°ot No. Sec. or Block No.
Lot Size `` = - House ✓ Mobile Home _ Business Speculation
No. Bedrooms I'4 No. Baths — No. in Family
Garbage Disposal YES ❑ NO p/ Specifications for System: \ ,
Auto Dish Washer. YES p� NO ❑ / c;c <, y, ) V _
Auto Wash Ma thine YESNO ❑ , ► ;;
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.
7
>improvements'permit bye
*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.
A•Y;
Final Installation Diagram: System Installed by "��/
Certificate of Completion -may Date ' I a 2 2-
'The
'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.
y
1
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section
P. O. Box 665
Mocksville, NC 27028 N O V O 7 1991
---------------
1. Application/Permit Requested By
Mailing Address � d Y 20:22 �d IifJ �cG il/G �O Oo'
Home Phone 9 S"o ) Business Phone
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 / ElOther [I Unknown
5. If house, mobile home: Subdivision Ndd e-6 M o.1-f )0/121"' �' /101 Section Lot#
❑ Basement/Plumbing
No. of People 4 El Basement/No Plumbing
No. of Bedrooms �h ® Washing Machine
No. of Bathrooms 3 K Dishwasher
Dwelling Dimensions 3 6 X ❑ 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: ® Public ❑ Private ❑ Community
8. Property Dimensions 5—AcRe, Sewage Disposal Contractor Oo,,9161 k �i
9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes X- 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
N�Z
Pee le5 CPNee� Rcaa
Ce ��
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 01SIGNATURE
CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY
MUST CHECK ONE: j>� 1. I OWN the property. ❑ 2. I 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 suitability for a ground absorption sewage treatment
and disposal system.
DATE SIGNATURE
DCHD(12-90)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
(� Soil/Site Evaluation Q
NAME y,RRA DATE EVALUATED
ADDRESS S Pr..� PROPERTY SIZE Ca
PROPOSED FACIILTY o s s` LOCATION OF SITE
Water Supply: On-Site Well Community Public
Evaluation By:C'l— Auger Boring Pit Cut
FACTORS 1 2 3 4
Landscape position
Slope % o - O - a
HORIZON I DEPTH LA-s
Texture group S C_ S C c-
Consistence F
Structure R
Mineralogy
HORIZON II DEPTH
Texturegroup
Consistence
Structure
Mineralogy
HORIZON III DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS SS S s .SS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTANCE RATESITE CLASSIFICATION: _ EVALUATED BY: �� n � 9-
LONG-TERM ACCEPTANCE RATE: ' �`S ��� OTHER(S) PRESENT:
REMARKS: "� C 'R . !�
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
Mineralo►
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
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' DAVIE COUNTY HEALTH DEPARTMENT �6 a
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTE:'Issued in Compliance With Article 11 of G.S.Chapter 130a
Sanitary Sewage Systems Permit Number
Name SA�2 �- \"\PZ\C L,VN Date ' "9� ND 6 33 0.
Location 11 ►� - Fj oo Wy��St Oy, 01 V \JJ -S �� 1 U b
la. crc-. U s, 1�a'� cam—a� � .
Subdivision Name 0No. 25 Sec. or Block No.
Lot Size House Mobile Home _T Business Speculation
No. Bedrooms No. Bat
'__hs �- No. in Family
C. .
Garbage Disposal
YES, p NO Q� ' s;
:v .. 1� � Specifications for System:
Auto Dish Washer ' 'YESS Q'- NO ❑
Auto Wash Ma.hine YES'-Q_' NOd ❑
Type Water Supply C o v°� Y v Lf
s `.
*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.
s
QIP®�>9ie5 TD.5��
Id
133
4.
Ry
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 704-634-5985.
Final Installation Diagram: System Installed by
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.
DAVIE ,COUNTY HEALTH DEPARTMENT ' /60 , bo
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTEfJssued in Compliance With Article 11 of G.S.Chapter 130a
Sanitary Sewage Systems Permit Number
Name S�,�a, L � P�'.�� _.` % 11 �Z, Date 3 '�� "}/ N2 6 33 0
Location `. >> ' fJ 3 ��o'��. �v h S� __ �� R. ` V ��-� -S 'Ll 1 U b
Subdivision Name r, r - ,!�k; Lot No. - Sec. or Block No.
- Lot Size House � Mobile Home _T Business Speculation
No. Bedrooms _ .No. Baths No. in Family
Garbage Disposal YES, p NO [B/
Specifications for System:
Auto Dish Washer` YES p' NO ❑ c3�
Auto Wash Ma shine YES Mal NO: p t
Type"Water Supply. t' o u Y _ Lf U U X I
*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. _
05 7-D
ti
fP�Kyy> > r
4 .
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 704-634-5985.
Final Installation Diagram: System Installed by
Certificate of Completion Date
'The signing of this cettificate 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
f✓ ' { Environmental Health Section
P. 0. Box 665 �t�p
Mocksvil le, NC 27028 $ RECEN-M MAI,;.
;.
1 . Application/Permit Requested By J4*11g ki1? GLIK
Mailing Address 2,1 � S $d2�oY.�-1-�t(2�st" '1ZjV lr._11r.14sf41_,53A,<+.c A4 Cr Z710j
Home Phone 19 q22' 1'7� Business Phone 9'I R 724-5azz-- .)
2. Name on Permit if Different than Above
3. Property Owner if Different than Above-r)-WRr�L WE2 wakc-i S!�Q[lLagjpge-
4. Application/Permit For: 0 General Evaluation (,go"S/Tank Installation
5. System to Serve: eHouse u Mobile Home 0 Business
L Industry Other 0 Unknown
6. If house, mobile home: Subdivision mwtG RW-C D.GeS Sec. Lott_ 3 _
No. of People 4 Dwelling Dimensions
No. of Bedrooms 1 17 Basement/Plumbing
No. of Bathrooms�- � Basement/No Plumbing
Washing Machine Dishwasher 0 Garbage Disposal
7. If business, industry, 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
8. Type of water supply: ePublic 0 Private Q Community
9. Property Dimensions [Q��- S.s 'X'3/9'a& �x ,39g'4,34- A Zpe"
10. Sewage Disposal Contractor r
11 . Do you anticipate additions/expansions of the facility this system is
intended to serve? 0 Yes eNo
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 applicat
3 �11 �t"L-.
Date Signature
Directions to Property :
6/D ar
S � fo- rz- AP'FF46. LOLDr-M&m 4 d �Ira�lS�
,- , 6 GM.t,.
15 5a Lk V60
DCHD (10-89)
_....._-___. -
T DAVIE COUNTY HEALTH DEPARTMENT-
ENVIRONMENTAL
EPARTMENT ENVIRONMENTAL HEALTH SECTION
2.5 1991
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. O. Box 665, Mocksville, N.C. 27028
Davie County Health Department
Environmental Health Section
Site Evaluation Consent Form
LOCATION OF PROPERTY: DATE RECEIVED
tarw3 CAWSf k1ix/GS va,/V& AfAVCfyn jfA' (office use only)
yes no 1. 1 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 -damNkL" WOOL-9M4(rner 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 property and conduct all
testing procedures as necessary to determine its suitability for a ground
absorption sewage treatment and disposal system.
� -al-mil
DATE SIGNATURE 0
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
.-LOnly those listed below
&tt2 kW-k, Gli/kud% z//S-SL3PaQrcNuxw o.- w-t
W/ JrW--ot1&%
1 �� inl a�lGlP.O. P�4 6.73co
Ss3 L
2/
DATE SIGNATURE
DCHD(11/84)
F
DAVIE COUNTY HEALTH DEPARTMENT
` Environmental Health Section
to Soil/Site Evaluation
NAME -S ZsNNW��- �+�\ N� DATE EVALUATED 3
ADDRESS S PROPERTY SIZE 6.2
PROPOSED FACIILTY ,oySQ LOCATION OF SITE A1?-c�IN,
Water Supply: On-Site Well Community Public
Evaluation Byl.;�Z-4,.L Auger Boring Pit Cut
FACTORS 1 2 3 4
Landscape position S S
Sloe 7.
HORIZON I DEPTH LQ" W,
Texture group t_ L
Consistence
Structure
Mineralogy
HORIZON II DEPTH b" 3n,,
Texture group
Consistence
Structure �r3
Mineralogy
HORIZON III DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS j
RESTRICTIVE HORIZON --
SAPROLITE — — -�
CLASSIFICATION Q S S 5 S
LONG-TERM ACCEPTANCE RATE 3
SITE CLASSIFICATION: � ,S 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-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
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