745 Gladstone Rd DAVIE COUNTY HEALTH DEPARTMENT 1 ,�
IMPROVEMENTS PERMIT AND ,CERTIFICATE OF COMPLETION
*NOTE: ssued in Compliance With Article II of G.S.Chapter 130a
tn.itary Sewage Systems Permit Number
Name Date _ ND
6652
Location
Subdivision Name Lot No. Block:;No.
Lot Size House Mobile Home _ Business Speculation
No. Bedrooms 3 No. Baths\ No. in Family .3 _
Garbage Disposal YES ❑ NO p,," Specifications for System:
Auto Dish Washer YES Q NO [e
Auto Wash Ma.hive YES NO ,[:]
O .❑
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.
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Improvements permit by
*Contact a representative of the Davie County Heal Department for final inspection of this system between 8:30-
9:30 A.M. or 1:00-1:30 P.M. on day of a mpletion. elephone Number 704-634-5985.
Final Installation Diagram: System Installed by 1/ �'l'a/
Certificate of Completion "�/ Date tL'
"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.
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APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PELFE
Davie County Health Department 21
Environmental Health Section 1992
P. O. Box 665
Mocksville, NC 27028
1. Application/Permit Requested By
Mailing Address ? '�s 6,A- 7` 7 ✓,6"l0 S<�/�� Q Z
Home Phone Q �e7 - -0� Business Phone 31 5 300
2. Name on Permit if Different than Above
3. Application/Permit for: ❑ General Evaluation _,Q-SVptic Tank Installation
4. System to Serve: House 2Mobile Home ❑ Place of Public Assembly
❑ Business ❑ Industry ❑ OtherUnknown
5. If house, mobile home: Subdivision Section Lot#
❑ Basement/Plumbing
No. of People 3 ❑ Basement/No Plumbing
No. of Bedrooms E]'Washing Machine
No. of Bathrooms 2 ❑ Dishwasher
Dwelling Dimensions - 7 ' W ❑ 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 �'ati % ❑ Private ❑ Community
8. Property DimensionsPT T1C1,e 5 Sewage Disposal ContractorZ IA
9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes ,�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 4thefmy know ed d I understand I am responsible for all charges
incurred fr m this application.
AE
�- DATE SIGNA UR
CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY
Fandd
ECK ONE: ❑ 1. 1 OWN the property. C�2. I 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 represent ' e of the vi ounty H alth a rtment to a to on abov escribed
cated in Davie County and owned by ` to - �✓� i✓Co
all testing procedures as necessary tc determines ' site's suitability for a rou d absorption sewage treatment
al syste
s
ATE 1G ATURE
DCHD(12-90)
f
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health .Section
Soil/Site Evaluation t� C
NAME [� a�W �R� PSN DATE EVALUATED d 1 2
ADDRESS PROPERTY SIZE �aA
PROPOSED FACIILTY LOCATION OF SITE
Water Supply: On-Site Well Community Public
Evaluation Byt"0--Auger Boring Pit Cut
FACTORS 1 2 3 4
Landscape position S S S
Sloe Z O - cs d -�° `fid. Q -
HORIZON I DEPTH 7 I ''
Texture groupL L
Consistence -Z F
Structure
MineralogX
HORIZON II DEPTH 3 6" 6
Texture group C C
Consistence L F t r L ' i-
Structure (3 K
Mineralogy Ilk 1l1 1 ISI
HORIZON III DEPTH I
Texture group
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS SS �5s s S
RESTRICTIVE HORIZON
SAPROLITE — — --
CLASSIFICATION S
LONG-TERM ACCEPTANCE RATE
SITE CLASSIFICATION: �� EVALUATED BY: \ � >
LANG-TERM ACCEPTANCE RATE: OTHER(S) PRESENT: Cr
REMARKS:
•v-
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.wateC 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/fu
DCHD(01-901