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215 Parker Rd � , '1 --i f,.,yam:: ... ,.,:,y- ;.,.:'..-,-.r-.a , Y r]' s , r. •'n . ... .. - DAVIE COUNTY HEALTH DEPARTMENT ~ „ IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION *NOTE:Issued in Compliance With Article 11 of G.S.Chapter 130a Sanitary Sewage Systems Permit number Name = N �. y Date .3 �5 � y N2 7 4 4 8 Location'—V,�C o� �-�� ;u �\VI , �.�• �_)U a� t�,+Li \ 4't(�\ C?�C 41. I� C1 Subdivision Name Lot No. Sec. or Block No. -t Lot Size House Mobile Home Business _— Industry No. Bedrooms 2d�3 No. Baths °`��-� No. in Family _ Public Assembly Other Garbage Disposal 'YES ❑ NO ❑ Secifications for ;System'` Auto Dish Washer YES 0 NO [3 Auto Wash Ma^hine, YES fv NO ❑ �vU �C J� X �� Type Water Supply 4-�- *This permiJXoid if sewage system described belo mot installed within 5 years from'date of issue. This permit is subject to'revocation if site plans t%e intended use change. \L 14. Q . J Improvementsp y permit b `— *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 RN—kik S I o N 11 w } f I Certificate of Completion 9- Date �-1-c 9L+6 '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 Davie County Health Department n Environmental Health Section , P. O. Box 665 Mocksville, NC 27028 MAR 2 2 1994 1. Application/Permit Requested By ;y( lt-YSAO- 'P Z-ke ro(-) w Mailing Address AoY a3YA Home Phone 70f- 45L92- 2fW 3 Moc-kSU�(lfe NC a'70--X-9 Business Phone 2. Name on Permit if Different than Above S qm& 3. Application for: O General Evaluation Coeptic Tank Installation Permit 4. System to Serve: ❑ House WMobile Home ❑ Place of Public Assembly ❑ Business ❑ Industry ❑ Other ❑ Unknown 5. If house obile hom Subdivision Section Lot# rnAoitc- K"'vw W�ul�6- ❑ Basement/Plumbing . No. of People R� �rgpfA , r1PnYaK. a-4 p-CIJI W ❑ Basement/No Plumbing No. of Bedrooms. ton., 3 ❑ Washing Machine No. of Bathrooms ❑ Dishwasher Dwelling Dimensions NJ-YtaAAA-#— - ❑ 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 l( Coync �° 1c 1 10 Or,F, 7. Type of water supply: ❑ Public Private mt U 'ty 8. Property Dimensions A5- f &Dor. Mr'Jfoy, T(4roLJs r � Contractor. 9. Do you anticipate additions/expansion rof the facility this sytem is intended to serve? ❑ Yes// I (No ?? If yes, what type? a fid, /noy'c. /h kle' 6i eyy-,- r /4&.-) e4 ;Z-•3 rs . '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: ��fe bel:,u)) Pr o p-"- i s ©ra, -', T o �ro �c"r �0 C-a Cc- 'Paltgw PId. LA ram U � Y1 ^, cl-,-.4' 4t - 5 L This is to certify that the information provided is correct to the best of my knowledge, and 1 understand I am responsible for all charge incurred from this application. DATE SIGNATURE x CONSENT FOR SITE EVALUATION TO BE DONE QN ABOVE DESCRIBED PROPERTY t MUST CHECK ONE: 1. I OWN the property. ❑ 2. 1 DO NOT OWN.the property. " If you checked Box#2,the rest of this form MUST be completed by the owner or a person authorized by the owner: I hereby give consent to the authorized representative of the Davie County Health Department to enter upon above described property located in Davie County.and owned by to conduct all testing procedures as necessary to determine said site's suitability for a ground absorption sewage treatment and disposal system. -7 C)'Z4 DATE SIGNATURE DCHD'(1193) ' GtJc. c:v�- cz Lai-`-fir f 1&4 . Y DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation q NAME DATE EVALUATED ADDRESS PROPERTY SIZE PROPOSED FACIILTY LOCATION OF SITE Water Supply:% On-Site Well Community Public Evaluation By: Auger Boring ✓ Pit Cut FACTORS 1 2 3 4 Landscape position .S -V Sloe Z a '�o O- 8° d -go7- HORIZON I DEPTH 1 1 Texture group Ol- L 1-. L— Consistence "� T Structure CV, Mineralogy I:I 1:1 HORIZON I.I. DEPTH » " Texture groupC- Consistence FIT Structure Y_ II K Mineralogy 1.1 HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH . Texture group Consistence Structure Mineralogy SOIL WETNESS Ss ,mss ms's RESTRICTIVE HORIZON SAPROLITE — CLASSIFICATION S .S 7F. S_ LONG-TERM ACCEPTANCE RATE N SITE CLASSIFICATION: (R.S EVALUATED BY: LONG-TERM ACCEPTANCE RATE: OTHER(S) PRESENT: N �'��a 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 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 r DCHD(01-9o1 ■■■■■■■■■■■■■e■■.■■■■■■■■■■■.■■■■■ecce■M■■MMMM■■■e■■■■e.■M■■■■■Me■ ■■..■■MM.M■■■■■MMM■M■■■■■■■■■■■■M■■.■M■■■■■■■M■M■■.■MMM■M■■■■M■■■ ■■M■■■■■e.MMMMM■e.■■■.M■■■■■■.■■ ■■/.e■M.M.e.eem■m.MM■M■■■■e.■m■■ ■M■M.MM.M.MMM■■■■■■■■Me.■■■ ■M■■■■■■MeM■M■■.t■■.■■■■■.e.M.MM■■m■■■ ■.■■■■M■■■■■■■■.■.■■■MM.M.te■.■e■■■.ecce■■■■Me■.■■■■■.■■■■■■■■■.■■ ■■■■■eM■■e■e■ecce.■■MeeaMee■m■eee■MMee■eem■M■eee■e ■s.M.m■M■eeee■e ■e■■■■■■■■■■■■■■■M■■e■Me■■■e■■■■■■■■■■e■MMee■eMM.■�ieMeeemet.■ee.m ■■eee.MMM■■■■■■O■■m■■e■e■■■eM.■e■■ ■te■e■■■■/■■n■■■■■■■■■ME■■■E/I� ■■■.■■■■■e■■■■■■■■■■■Mese■■■■e■■■■=■eMM.■e■een.t■e■tMe.m.M.m■ee■■ ■■■■■■Me■■M■■■M■■e■■M■e■.■■■■e■■■■■■e■M■MOMe■e■e■■■■M■me■■■e■■=■■■ ■eee■■■neo■■e■M■■Mm■MeemM■■■■■■�etetMtm■M�M■M■MEeMeMMMmtMeMe ■.■ ■.eee.eee■tee■e■■eoeeMe■■MtMm■Ike■■e■.■e■e.t■■■■n■t■■�■ee■eeeee■■I Me■■■eee■e■M■MMM■ee■■■■■■.s■■■!�e��r■■■■.■■■M■M■e■M■Me■e Me■ee■MeM■ ■EMEM.m■■■M■M■Mt■e■■■MM■MeeMMM`.t.■mMtMeMmMtm■eeMe■ ne■eM■Meme■e�iM ■eM■M■M■eee■■e■e■eee■MM■MM■Mel►e!r�;M�ieM■M■m■mem■t■e■ ■e■■■e■ m■m■M■t■ ■■■■■■■■t■■eM■■■M■■eeMeMMMeM►v�lr■ ■■■M�reeM■M■m■■Mtmm■■MmM�iM■mMMMe■ ■■M■■■■■■■■■■t■■■■■MeMeMtM■M■�eM��■/Mmur►:■e■t■■ ■E■■t■■■■ ■Moe■■■■ ■tMEM■M■■me■MtM■eee.ITnac�sM■a■MeMeM■M■r�rE■■eeeeee■■t■e■eee■ MmM■Mee■ MNEMEeee■m■M■■eMMMM■I,se.�■M■■■M■t■e■■■r1-;.1ir,■■■■■■■■■■■■■/■■■�■■■■t■■■ ■■■e■■■■■■■t■e■e■■■.�.t■r•■■■r!leer.■■■��■1�t■m■■M/■■/■t■m■■■m■■M■M■■ ■e■e■tM■M■eel■■eMer�r,Mc■,►,t■■r■eee■■e�►e■m■ ■e■e■■n■■■M■M■■■■■M■e■■■ ■■M■M■e■M■m■ecce.■��i:a��>•��■■e■m■m■meee■m■■■m■m■■■■■E■■■■■ ■■■■■■■■■■ iiiiii�iiiiii'numMoiiiiummomm"MmufcuONEMOMiim" ■■■■■M■■■■■e■►.�\■■/%\�ee�:/■■eoe■mtM■■ ■l�■■m■e■■■■e■tees■mM■eee■m■ ■■■■■■■■.■■■■%1111l�M■//ett■■Me■■■/■m■■■�■ ■■t■■■ ■/MEMO■■e■■e■/■■ ■■■■■■■■■M■■■\�.a//E\��i1■t■M■M■■■Ee■OMOt■ MM/MME ■imommoME■■tome■ .mem■■■M■.■ee�r■■MVM�IM■Mo■■gym■e■M■/eee ■■m■mM ■ mmommommoomMEMMUMMIMMEEMMIN Mm■ ■tM■■■■O■■■■MmMlll■■tMtr�V■te■IN■IMl1l1!A■■=E■011 lom■ US ■//■EEM■/EOEE■EIUEEE/MEE■■E■l/aJ/LIWI�/E ■■.�l.l�tE�EE ■EE■■E/E■■■■E■Et NEE :0 MUME Milo u Mims mommommm ": MMMM■■■ ■■/■M■■MEM ■MMOMM■OMMEMEM■ mmo.lum ■ i.■■ ........ ..... mmosomm :C:CC:::C::::::C:C:C:::::::::::I:::� ::":::::MMOMMER:: iiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiii'■i'■ii�i��s iiii'■MEi'iiii�iiiiii"ie' ■.■.■.■■■■■MM■M■■■■■■■■■■■M■■■■■�■■M■■M■1=MM■Me■t>tMeMMt■■M■■■■=i'MeM■ ■■■M/eM■■MMMMMMMMM■MMM■■MM■■■MM■ ■■■MMMIII e■��■11llIMe■■■■■■■■■■■■■■■ ■■MMMMM■eeeee■■■eMee■■MMMMM■■M■■.MMMMMMe1i MMr�- MMI�e■■MMMe■M■MMe■■eM ■■■■■■■■/■n■■■■■■■■■■M■Mm.t■M.■■m.■Me.■1� ■■�c�i■Ml�eee.MMMMe■■■Me■.■ .C■M■e■ eMMM■e■eMM■MMM.■.M.c.C.M.M.■.■.M.■.■MsM:e:M.M.e.e.l�.>,eeM...r:r..e.�°>1t:■M:M:O:M:M:E:M:M:O:M:M:EM:M:EM noM■■MM :Me:■■::■::■E : M■e■■■■■■■■ , ■■■■eMl�■■M■w�le�loM■■■■■M■■■■■■.■■ ■■■■■■■■■■■■.e.e.t.■s■■Me■eMenM■t■■■M1�■l�■■■E■e■�1■tMe■■M.neeM.■■■ ■■■■■■■■■■■■■■■■■■.■■■■■■■■■■■■■■■■■■■■Eli■■■M■■■1�■■■■■■O■/■■■■■■■■ ■■/■�■■■■O■■■■■■■■■■■■M■.■■MMeee■■■■■■■■I■■■■■■■■11■.■Mee■■■■■/■■/o■ ■M■■M■■M■■■■■■.■■■■■■■e■■■eee■■ ■■■■e■111■e.■■eM1�ee■■M■■■■eee ■■■■■ ■■■■■■■MmMM■MM■■■■M■■■■■■■■■■en■■■■■eMue■MM■e011MOMMEMMMEMMM■e■M■