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1833 Milling Rd ... y k. ....,;rr ;- �i :aa, r t.:, 'L.Y.• 7 s ..'�:j. .- aµ. �.y-'.-.- - .. ..._ c-, - ; `� DAVIE COUNTY HEALTH DEPARTMENT 11 .30 t.� IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION , *NOTE:Issued in Compliance With Article,ll of G.S:Chapter 130a Sa nary ewage Systefn t7 6 _ Permlt•�Iu or Name _ �� Date N2 ` r L ion; 1 � \1 N� �• �`, �� c�`.}�..1.;:r'�Jf-T�J.e ''�'`�.y.-� �---' --�-'`��:,�^rJ J�-... \S,�;-��-" l..)�'�:;s } r... Subdivision Name Lot No. Sec. or Block No. 1 • `a :� � V Lot Size House Mobile Home _ Business Speculation No. Bedrooms No. Baths No. in Family .Garbage Disposal YES Q NOj p� ificalior�s foL_Syste.m: Auto Dish Washer YES Q. NO Auto Wash Ma.hine YE b NO ❑ t� �v► + + ,��, 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. a S 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 bye° '� VoRc� . 0 J Certificate of CQrmpletion ` sem Date The signing of this certificate shall indicate that the sy t' m descridove has been installed in compliance with the standards set forth in the above regulation, but shall in%Q way betake ove a guarantee that the system will function satisfactorily for any given period of time. \� �� APPLICATION FOR SITE EVALUATIOWIMPROVEMENTS PERMIT Davie County Health Department 0 ; 0 V Environmental Health Section P. O. Box 665 Mocksville, NC 27028 1. Application/Permit Requested By C140ARLES ETHERIWOE Mailing Address fT 3 Bey (Q76 Home Phone w• 5OQq 25.2j A DC"VIL E . >JC., 2'i OZB- q aC?3 Business Phone 125-- 2. . Name on Permit if Different than Above 3. Application for: ❑General Evaluation Q Septic Tank Installation Permit 4. System to Serve: [5' House ❑ Mobile Home ❑ Place of Public Assembly ❑ Business ❑ Industry ❑ Other ❑ Unknown 5. If house, mobile home: Subdivision Section Lot# Basement/Plumbing No. of People 2 ❑ Basement/No Plumbing No. of Bedrooms 2 Z Washing Machine No.of Bathrooms 3 ® Dishwasher Dwelling Dimensions 3Z 5 X q).5+ ❑'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 11.165 ACRES Sewage Disposal Contractor 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes I1 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: ffAIN sT /)SID To M1tIMP ARD To DurtJJAJ4N 6R£4.X $Rr,D6P, (5'uST P467- &IN 4) � IST DAWEWAy ON LV—FT AWMe BR%D&E . FmLoc) VKWEWAy 'To DEAD END AT +GORSE SARK AND GATE- �JuST INSIDE -rAE PEMCE To TµE R1m-IT vp w ?NE KuOLL 15 PRoPIDSED �JOVSE SITC. This is to certify that the information provided Is correct to e b st of my knowledge, and I u derstand I am responsible for all charges incurred from this application. DATE SIGNATURE CONSEN OR SITE EVALUATION TQ BE DONE ON ABOVE DESCRIBED PROPERTY MUST CHECK ONE: UTT. I 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 suitability for a ground absorption sewage treatment and disposal system. DATE SIGNATUR WHO(71P ' DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation NAME `�. �- Q DATE EVALUATED q3 ADDRESS PROPERTY SIZE �M� e b S 01 s PROPOSED FACIILTY ° gP LOCATION OF SITE \`\ �� `N R Water Supply: On-Site Well ✓ Community Public Evaluation By: Auger Boring ✓ Pit Cut FACTORS I 2 3 4 Landscape position Sloe Z 16° 77-o HORIZON I DEPTH G to " Texture group CL CL CL L_ Consistence1�'FT_ Structure Mineralogy1; � \'•\ 1'• HORIZON II DEPTH LI " Li Texture groupL S CL CL CL Consistence FZ F_]�- Structure T:7—_- -77— Mineralogy :R77Mineralo HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS S s s s s s s s RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION S .S S. S LONG-TERM ACCEPTANCE RATE •V , SITE CLASSIFICATION: Q ' EVALUATED BY: LONG-TERM ACCEPTANCE RATE: OTHER(S) PRESENT: REMARKS: LEGEND Landscape 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 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(01-90) ■.■..■■..■.■■.■■■■■■■■..■■■■..l...■..■■.■■■■■■......■e...■ ■■NOON■ ■■....■■■■.■■■■■■.!!.!.■.!■...■.■■■i■■..■■.■■.■■.■■■■■■■.Nee■.■.■ ■■■■■■■■■.■.■.■■s..■■...■.■■■■.■■.■■■.■■Nee....■..■■...■■.■...■■■■ MINN ■■■.■■■■■■.■■...■■■■■■■E■...■■..■■■■■■....■.■.....�.■■■!■!■.■.■■. 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