145 Gobble Ln DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTE:Issued in Compliance With Article I I of G.S.Chapter 130a
Sanitary Sewage Systems Permit Number
Namet" ,�? l 't f 1% / l/,,,,i'•: Date .r ,�'i�f`i'.' N2 6071
Location !%� . 7` 1 '�/�- t' / i ;`,:,i.—c .'�% .r, Pte✓ /�` '' .
Subdivision Name Lot No. Sec. or Block No.
Lot Size /u'r House Mobile Home Business Speculation
No. Bedrooms -.-SE No. Baths No. in,Family _
Garbage Disposal YES ❑ NO ❑ Specifications for System:
Auto Dish Washer YES ❑ NO ❑ eeo C. rG
Auto Wash Machine YES E] NO ❑ f
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.
I
Improvements permit b
,
*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
bo
Z � , 1ci'f
7r ��
r-
Certificate of Completion Date
*The signing of this certificate shall indicate that the system described above has been installed in comp ance 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.
-�a
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
l Soil/Site Evaluation J
NAME DATE DATE EVALUATED
PROPERTY SIZE
ADDRESS P /��
PROPOSED FACIILTY LOCATION OF SITE �'`
Water Supply: On-Site Well Community Public oil
Evaluation By: Auger Boring Pit Cut
FACTORS 1 2 3 4
Landscape position L L
Sloe Z
HORIZON I DEPTH
Texturegroup $� S S
Consistence
Structure
Mineralogy
HORIZON II DEPTH
Texture group
Consistence
Structure
Mineralogy / / .•
HORIZON III DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE
SITE CLASSIFICATION: EVALUATED BY:
LANG-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-Finn 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
DCHD(01-901
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APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT /lp/W
Davie County Health Department
Environmental Health Section
R O. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone(704)49.2'5118
1. Permit Requested By Q rent Cobble Business Phone "
2. Address Rt. l Box I18 A MisGkSVi IIc, NC ff7628
3. Property Owner if Different than Above
Address
4. Permit To: a) Install Alter Repair
b) Privy Conventional Other Type
Ground Absorption
c) Sub-Division Sec. Lot No.
5. System used to serve what type facility: Housed Mobile Home Business
Industry Other
b) Number of people �+
6. aT If house or mobile home, state size of home and number of rooms.
House Dimensions 75 x 30
Bed Rooms 3 Bath Rooms 2 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 I washing machine
dishwasher 1 sinks
8. a) Type water supply: Public Private Community
b) Has the water supply system been approved? Yes No
9. a) Property Dimensions I 01G1'e
b) Land area designated to building site
c) Sewage Disposal Contractor
10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve?
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What type?
This is to certify that the information is correct to the best of my knowledge.
7-4- 90
Date Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
44 W -fa Shc;field Rd.. / mile Pas+ lamas Church . Turn in-16
d
rive, by Larry evhblGs 113 Go b bles. Staked on lelf cif
Cu rve .
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DCHD(6-82)