168 Murchison Rd •.a11 .. ..
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DAVIE COUNTY HEALTH DEPARTMENT
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IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION. pKoy
*NOT_E:Issued in Compliance With Article II of G.S.Chapter 130a
San tary Sewage SystemsPermitNumber(�
Name _ ` - Date � r NO /'7 G.28
1`
Location
Subdivision Name Lot No. Sec. or Block No.
Lot Size Housed_ Mobile Home = Business Speculation
No. Bedrooms No. Baths No. in Family _
Garbage Disposal YES ❑ NO Lill, Specifctions;:tor System, r
Auto Dish Washer YES E]] NO �] `�`j
Auto Wash Ma-.hive YES NO ❑ �j�' 1 �( '���
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-U
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: f System Installed by
r"li J-
ry
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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.
v I ATION FOR SITE EVALUATION/IMPROVEMENTS P
RMIT
Davie County y HeaI h Department 1993
91993 Environmental Health Section
1993
P. 0. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone
1. Permit Requested By LZL/2 Business Phone
2. Address �7L / � —L3-2 T�C rV—toe(
3. Property Owner if Different than Above
Address
4. Permit To: a) Install Iter Repair
b) Privy Conventional Other Type
Ground Absorption
c) Sub-Division Sec. Lot No.
5. System used to serve what type facility: House Mobile Home Business
Industry Other
b) Number of people
6. a)If house or mobile home, state size of home and number of rooms.
House Dimensions�Zr0
Bed Rooms '3 Bath Rooms Z Den w/Closet
b) If Business, Industry or Other, State: Number of persons served
What type business, etc.
Estimate amount of waste daily (24 hours)
7. Number and type of water-using fixtures:
commodes urinals garbage disposal
lavatory showers washing machine
dishwasher sinks
8. a) Type water supply: Public PrivateJal __ Community—
b)
unityb) Has the water supply system been approved? Yes No
9. a) Property Dimensions
b) Land area designated to building sites
c) Sewage Disposal Contractor I
10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve?
What type?
This is to certify that the information is correct to the best of my knowledge.
7- 5 — �3
Date Owner Si
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
_
A/U
DCHD(6-82)
a
DAME COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation p
NAME h '� �� 1 DATE EVALUATED
ADDRESS s 'A'NP PROPERTY SIZE
PROPOSED FACIILTY 1 ' ` \� ° LOCATION OF SITE yK\
Water Supply: On-Site Well Community Public
Evaluation ByQ,ti— Auger Boring I/ Pit Cut
FACTORS 1 1 2 3 4
Landscape position s -S S
Sloe 7. 6- B" v - o' ` E
HORIZON I DEPTH " �� " ►2' 7�
Texture groupL �—
Consistence ? I, r 1•
Structure CJ-e- C R
Mineralogy
HORIZON II DEPTH b 3 t- -316
"
Texture group C; e-1 C
Consistence _ -E V-T VT
Structure <
Mineralogy
HORIZON III DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS SS sS S SSS
RESTRICTIVE HORIZON J
SAPROLITE —
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE 1A y t y 1y (°
SITE CLASSIFICATION: J 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
Mineralo¢Y
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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