476 Mr Henry Rd ` K DAVIE COUNTY HEALTH DEPARTMENT bb , C,a
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION 0b .
*NOTE:IssueQn—Compliance With Article 11 of G.S.Chapter 130a
Sanitary Sewage Systems Permit Number
Name . \ -> x.\-, `' .�` ` .�'�._l . t� Date ND 6202
Location �wZ �`:�� � '. �;`f,C? ,.��!� �, � w \M
c:1."�.�. �.,��v ,.:3:•� ��-`,�� ,^...1;—�:s✓,}�
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 Q !1 t_. c ;
Auto Wash Machine YES 2' NO ❑ >�ti `-; �, 71
Type Water Supply C•.C}- ---
*This permit Vdid if sewage system described below is not installed within 5 years from date of issue.
This permit s sVbfecft to revocation if site plans or the intended use change.
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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
! V
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 'T�U
r ' Davie County Health Department
Environmental Health Section
P. 0. Box 665 F,��1V�U NOV D 5
Mocksville, NC 27028 R
11 1 �
1 . Application/Permit Requested By F t 211NP.-I'1' I\�. Ear
Mailing Address Rntjp_ 7T,BOX "59,8- 1 1. m fNC' S u;1F-7LO- 2
Home Phone 7by- yqa- ,53y Business Phone 141- G�3y -- 561.1 _
2. Name on Permit if Different than Above
3. Property Owner if Different than Above 'n Y1 _PS f w ;1 1Q,MS
4. Application/Permit For: 0 General Evaluation R1**`S/Tank Installation
S. System to Serve: House Mobile Home Business
L Industry u Other 0 Unknown
6. If house, mobile home: Subdivision Sec. Lot#
No. of People Z Dwelling Dimensions
No. of Bedrooms 2 Basement/Plumbing
No. of Bathrooms 2 ` Basement/No Plumbing
(Washing Machine J 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
S. Type of water supply: C Public 91-Private Community
9. Property Dimensions lQ_Q_t1/'wpp
10. Sewage Disposal Contractor
11 . Do you anticipate additions/ex ansions of the facility this system is
intended to serve? 0 Yes 7o
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 application.
f
Date Signature
Directions to Property :
From Mocksv►lle► &D oU� prison CaM� �oQd. Twcn le l- on Gcee►h�1��00► 1 Tu.�r,a. ri�ly�
6n 00-uie Acoxlemy Road. Go -6 cno6ssoads. T�.cn lePl on fir, N"r1lo NaJ.
l ►tiu,�e 0-y% r• `� �° W1 ���� �ensian p owes. lines,
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DCHD (10-89)
?� DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
NAME �'�.� � �`�`� DATE EVALUATED j $ ' `T b
ADDRESS PROPERTY SIZE fMOO
PROPOSED FACIILTY VN• � - LOCATION OF SITE tS\9.. 1�3JNVa�S 1�
Water Supply: On-Site Well Community Public
Evaluation Byt�_,l._ Auger Boring Pit Cut
FACTORS 1 1 2 3 4
Landscape position S 1 S s
Sloe Z O - g° G -8<4 Cj _ (_�
HORIZON I DEPTHT-771
Texture grOu2C L L
Consistence F-1 FT F
Structure C Q
Mineralogy ► ) " I I 1 ! 1
HORIZON II DEPTH 1 LI 0
Texture group t
Consistence 1Pi- PT
Structure p
Mineralogy
HORIZON III DEPTH
Texture grou2
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS S S .S S
RESTRICTIVE HORIZON —
SAPROLITE r
CLASSIFICATION I kS3-S 1 .5 S
LONG-TERM ACCEPTANCE RATE -y,b I ,S'- yo
SITE CLASSIFICATION: EVALUATED BY:
LONG-TERM ACCEPTANCE RATE: �� y '� 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
Mineralolzy
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