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425 N Pino Rd .. '...-• •"U,..r ,y c,:. ae :.rr i>,, "`DdY n. t,.. .:.- • -. r v, .. .- .'- vc- DAVIE COUNTY HEALTH DEPARTMENT iya V IMPROVEMENTS PERMIT AND ;CERTIFICATE OF COMPLETIdNi,� f �o iNOTE:Issued in Compliance With Article 11 of G.S.Chapter 130a Sanitary.Sewage Sstems Permit Number Name.— _�' j © \� �'� _ Date / i y N2 1 6 4 " , Location � � _ ��1 � o 1_1�.1S v ���� � •�. .��t)d..`� Subdivi ion Name Lot JaIA:.. Sec. or Block No. ~,.w Lot Size House Mobile Home —'� Business__ Industry_,_ .. No. Bedrooms `.� ° No: Baths 1`° `''" No. in Family _ PubliaAssembly ti ther. �, ss .. , tls Garbage Disposal -YES ❑ NO �el-', Specifications for System: - Auto Dish Washer YES4] NO Auto Wash Ma,pine` YES [� NO ❑ ti . "� o�+ Baa ' Type,Water Supply f . .. This permit`Void if sewage system described'66low is not.installed„within 5 years from date of issue. This permit is subject to.revocation if site plans or the intendeld,use change. r / /'.0 ,• f Ct 4 1 100 1 � s i i 0v1 ` .�. 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 J c.�T_�� 'E' �`A- N nW� F Fv�N )coir � v ' Certificate pf Complet:ion ` ' , .:Date 'The signing of this certificate sh<indicate that the system described above has been installed in compliance with the standards set forth in the above regulation, but shall in IJO way be taken as a guaranty that the system will function / satisfactorily for any given period of4ime. i s / APPLICATION FOR SITE EVALUATION/IMPROVEMENTS Co Davie County Health Department @ U V Environmental Health Section D P. O. Box 665 V 1 Mocksville, NC 27028 1. Application/Permit Requested By &07-7 Por Mailing Address ' f;�"c I Home Phone Ale—' 2-7t)3-6' Business Phone Jd8'—/7e,y 2. Name on Permit if Different than Above 3. Application for: ❑General Evaluation Septic Tank Installation Permit 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 a ❑ Basement/No Plumbing No. of Bedrooms '�' Washing Machine No.of Bathrooms ❑ Dishwasher Dwelling Dimensions qk S-V ❑ 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 Sewage Disposal Contractor 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes ,4-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: tj P � .10 This is to certify that the information provided is correct to the bestof my knowled e, and I understand I am responsible for all charges incurred from thi applic tion. 1 -� DATE SIGNATUTIE CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY Fanddisp9sal ECK ONE: ❑ 1. 1 OWN the property. X2. 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 p the Davie County health Department to enter upon above described cated in Davie County and owned by (' /e. .�� all testing procedures as necessary to dete ine said si 's suitability for a ground absorption sewage treatment sy tem. DATE SIGNATURE DCHD(193) f , _ /♦ DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation NAME C`�\ DATE EVALUATED a - ADDRESS OM�'S`c- PROPERTY SIZE PROPOSED FACIILTY \`\ �6`t`�Q LOCATION OF SITE Water Supply: On-Site Well v Community Public Evaluation By:0�,�Auger Boring Pit Cut FACTORS 1 2 3 4 Landscape position 3 S Sloe Z 6 -° Y- 75 HORIZON I DEPTH '' !P, -2 " 1 " TexturegroupC Consistence Structure Mineralogy HORIZON II DEPTH Texture group Consistence T 7 7- Structure Mineralogy ' HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS S RESTRICTIVE HORIZON -- SAPROLITE CLASSIFICATION _S LONG-TERM ACCEPTANCE RATEI Xb 2 SITE CLASSIFICATION: � EVALUATED BY: LONG-TERM A CEPTA�VCE RATE: b� OTHER(S) P ESENT: REMARKS: �� � - " LEUND 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(01-901 .............................................. ........ .......... 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