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487 Ben Anderson Rd (2) . � 4� o ~' DAVIE COUNTY HEALTH DEPARTMENT -IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION 'NOTE:Issued in Compliance With Article II of G.S.Chapter 130a ' Sanitary Sewage Systems, Permit Number Name ---� C,,za 'e� c' 7-r,a - Date C� �_ N2 8155 Location ` z1 3 _r..� �. r �.. �v�• �c^c. �_7�.:,_�. , ��:t ' 4 ...;,, 1'� tic., �s:�,.��.rr�w.�?.r�rr� Subdivision---111 me lot No. Sec. or Block No. Lot Size House — t Mobile Home _ _ Business -- Industry No. Bedrooms _.No. Baths __L— No. in Family 3 — Public Assembly Other Garbage Disposal YES ❑ NO Ell' Specifications for.System: Auto Dish Washer YES ,_, ❑ NO LTJ" CZ) Auto Wash Ma-hi ne YES M/ NO ❑ Sao 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 ATTENTION:,ti YOUR SEPTIC SYSTEM CONTRACTOR MUST SEE THIS PERMIT/LAYOUT BEFORE INSTALLING THIS SYSTEM. 1 loot' i Improvements permit b Y `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 M 4� b r a Certificate of Completion _ Date - r! '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. 44 APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PE �r � Davie County Health Department4 :- -' Environmental Health Section . 9m P. O. Box 665 . Mocksville, NC 27028 1. Application/Permit Requested By" 15"n do Is�6 Mailing Address 1/9 7 1?P_/I �/,1,d/ F,50 e\. Home Phone (,7,O! �Z fo? 0C L5/-1 del /V 10A9 Business Phone to-6#---5'0 A I 2. Name on Permit if Different than Above 3. Application for: ❑General Evaluation C§'Septic Tank Installation Permit 4. System to Serve: ❑ House f mobile Home ❑ Place of Public Assembly ❑ Business ❑ Industry ❑ Other ❑ Unknown 5. If house, mobile home: Subdivision Section Lot # ❑ Basement/Plumbing No. of People 3 ❑ asement/No Plumbing No. of Bedrooms ( Washing Machine No. of Bathrooms ❑ Dishwasher Dwelling Dimensions '' ❑ 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 i r'Private ❑ Community 8. Property Dimensions I1%� a y 01 .SD C"I'L te4age Disposal Contractor 9. Do you antidipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes 2TIN'o 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: 6114/ S / �� C f� `r d 60 A)dt-k -A0 n� O a 60 ,4- 4e 3 �f��S I� ,S/ dgA IO g�f e s p it Ave- R,� �� 0� 4,& /e rJ' / Q W h•1e- ,)6a4ke- A A- .&JAI faarg4' This is to certify that the information provided is correct to the best of my knowledge, and I understand I am re ponsible for all charges incurred from this application. I g-cls DATE SIGNATUR CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY MUST CHECK ONE: ❑ 1. 1 OWN the property. [Z/2. I 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 HealthDepartment 9 to enter upon above described C property located in Davie County and owned by d C4 L ) to conduct all testing procedures as necessary to determine said site's suitability for a ground absorption sewage treatment and disposal system. DATE SIGNATURE DCHD(1/93) 'i DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation NAME N oto Q r F N DATE EVALUATED < -A 96 ADDRESS 'N M'Q PROPERTY SIZE � wzll_n PROPOSED FACIILTY W:�) LOCATION OF SITE Water Supply: On-Site Well ✓ _ Community Public Evaluation Byfi'�.1- Auger Boring Pit Cut FACTORS lo 2 3 4 Landscape position -S Sloe Z g'1 v 0 6 HORIZON I DEPTH 11 �� Sl' Texture groupC �- L Q_ Consistence Structure C� MineralogyHORIZON II DEPTH a v" 0 Texturegroup C. C Q_ ConsistencerT1 FYI Structure bv-- MineralogZ HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS SS" RESTRICTIVE HORIZON -- SAPROLITE — -- CLASSIFICATION LONG-TERM ACCEPTANCE RATE , , 1 SITE CLASSIFICATION: �� EVALUATED BY: `JF7�o • 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 :lay loam. SIL-Silty loam CL-Clay loam SCL-Sandy clay loam SC-Sandy clay SIC-Silty clay C-Clay CONSISTENCE Moist VFR-Vcry 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 ■■■■■■■■■■■■■■■.■■■■■■■■■■■.■■■.■■■■■■e■■■■■■.■■■/■■■■■/■■ ■■ EOE■ ■■■M■MME■E.MEMM■EE■MMEMMMEMMMEMMM.■■.MMIEECECEEEEE■EEMEE■EMEMM.EEM ■■■EEEEEE■EE■EEM■■MMES■EIEEEE■E■■E■■■.■..■■■■■■■■■■■■■■.■■■■■■■■■■ .......................................... ........ ............. ................................ ................. 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