263 Mr Henry Rd ••:q..r.c, r.i ..,: ...:. -,.fir .. ..•. , , .. .- ., �.-. L
DAVIE COUNTY HEALTH DEPARTMENT
// IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTE:*Issuedrn Compliance Wi ,Article I I of G.S.C apter 130a
San' ary Sewage Systemseyo Perm7381
it Number-
Name ! D e ,�� " 9� N2 13 8 I y
Location I ! ✓ �'[�c'L--L�� .uf "
r
Subdivision Name Lot No. Sec. or Block No.
Lot Size ����, House Mobile Home Business Industry
No. Bedrooms —c:2 .No. Baths -- No. in Family — Public Assembly Other 1
Garbage Disposal YES ❑ NO S- Specifications for System:lQde�ga–C.
Auto Dish Washer YES } NO ❑
Auto Wash Ma thine YES T 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.
A
y
r
f
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.,
1:00-1:30 P.M.or 4:30-5:00 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.
�►"� - APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
C
�t Davie County Health DepartmentD
�+ Environmental Health Section / `' 1tT�I
P. O. Box 665
Mocksville, NC 27028C^r /J1,11
FEB
1. Application/Permit Requested By
!e r�
Mailing Address
Home Phone DC S V1//a/ a 7q ess Phon �� ��JO
2. Name on Permit if Different than Above
Ag
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 ❑ Basement/No Plumbing
No. of Bedrooms fir, - ❑ Washing Machine
No. of Bathrooms �� ❑ Dishwasher
Dwelling Dimensions ❑ 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 K Private ❑ Community
8. Property Dimensions e S Sewage Disposal Contractor
9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes tf 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:
This is to certify that the information provided is correct to the best of mywl dge, an I under tand I am responsible for all charges
incurred from thi pplicati
DATE SIGNATURE
CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY
Fandd
ECK ONE: ❑ 1. 1 OWN the property. 19 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 o he Davi CountyHealth Department to enter upon above described
cated in Davie County and owned by � � Z
all testing procedures as necessary to deter me said e' suitability for ou d absorption s age treatment
al system.
DATE SIGNATURE
DCHD(12-90)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
NAME /�� `� DATE EVALUATED
ADDRESS PROPERTY SIZE
PROPOSED FACIILTY }�dus a LOCATION OF SITE
Water Supply: On-Site Well Community Public
Evaluation By: Auger Boring V, Pit Cut
FACTORS 1 2 3 4
Landscape position
Sloe % t
HORIZON I DEPTH Li'' G'• "
Texture groupL r.0 S•C.
Consistence
Structure
Mineralogy
HORIZON II DEPTH /Sl I Ab•�
Texture groupG.
Consistence
Structure .0577
Mineralogy
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
Q /
SITE CLASSIFICATION: /, //!.'`��j .! EVALUATED BY: A4:�/
LONG-TERM ACC E TANC JRATE: .. OTHER(S) PRESENT:
REMARKS: , (.- a///IGLy�i✓
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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• Davie County .dealt!• De artment
and .Moine .fealtlf Ayency
210 HOSPITAL STREET P.O. BOX 885
MOCKSVILLE.N.C. 27028
PHONE:(704)834.5985
February 16, 1993
Shirley M. Mabe
c/o Howard Realty
Attn: Red Foust
330 S. Salisbury St.
Mocksville, NC 27028
Re: Site Evaluation
Mr. Henry Road/6 Acres
Dear Ms. Mabe:
As requested, a representative from this office visited the aforementioned
site on February 15, 1993. The site was found provisionally suitable for the
installation of a modified-oversized ground absorption sewage system.
If you have any questions, please feel free to contact this office.
..Sincerely,
i
Robert B. Hall, Jr. , R.S.
Environmental Health Section
RH/wd
Enclosure