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165 Mac Ln V J 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 p1 �,�%-�%� Permit Number Name S /a A/�4': ,.I t o °�`��'Y at ' 71 N2 6478 Location /0 :�� f �/ .� �� 1 /) a-- -r r r r ,..,�i �T ,, ✓-•r/ a — Subdivision Name Lot No. Sec. or Block No. e Lot Size /,i nn:Y %r?�� House Mobile Home _ �� Business Speculation No. Bedrooms '0 No. Baths — _ No. in Family 49 — Garbage Disposal YES ❑ NO Specifications for System: Auto Dish Washer. YES NO ❑ J Auto Wash Ma:hine YES 4'� NO ❑ � �� `a 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. 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. or 1:00-1:30 P.M. on day of completion. Telephone Number 704-634-5985. byF'nal Installation Diagram: System Installed , F17 /C(ertificateof Completion Date *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 R satisfactorily for any given period of time. APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT s Davie County Health Department '. Environmental Health Sections;: P. 0. Box 665 Mocksville, NC 27028 J. 1 . Application/Permit Requested By Mailing Address 11�+. I, TUX 30A Mocksyilte mc, 1,78ol Home Phone ,��I-�Iq`� �b �Q Business Phone 2. Name on Permit if Different than Above 3. Property Owner if Different than Above 4. Application/Permit For : General Evaluation S/Tank Installation 5. System to Serve: House ( $ Mobile Home 0 Business Industryu Other 0 Unknown 6. If house, mobile home: Subdivision Sec. Lott' No. of People Dwelling Dimensions 14x'10' No. of Bedrooms Basement/Plumbing No. of Bathrooms Basement/No Plumbing 13 Washing Machine Xj Dishwasher 0 Garbage Disposai If business, industry, 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 8. Type of water supply: C Public ® Private 0 Community 9. Property Dimensions 10. Sewage Disposal Contractor 11 . Do you anticipate additions/expansions of the facility this system is intended to serve? 0 Yes No If yes, what type? *NOTES 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. This is to certify that the information provided is correct to tree best of my knowledge, and I understand I am responsible for all charges incurred from this application. Date Signature Directions to Property : an Iboo .rmo� \." Ur 'DA M aur '-R&UN I= #) to ql_ae �d a00-6 ,nc�a�l o o� .dot "ITn ,.apc_.L can eau DCHD (10-89) l � ' DAVIE COUNTY HEALTH DEPARTMENT ENVIRONMENTAL HEALTH SECTION SITE EVALUATION CONSENT FORM 1. Complete the form below and return to the Davie County Health Department. 2. Carefully follow the procedures as outlined in the enclosed "Information Bulletin." NOTE: THE ABOVE MUST BE COMPLETED BEFORE A SANITARIAN WILL BE ABLE TO BEGIN THE REQUESTED EVALUATION. DETACH HERE AND RETURN TO: Davie County Health Department, Environmental Health Section, R O. Box 665, Mocksville, N.C. 27028 Davie County Health Department Environmental Health Section Site Evaluation Consent Form LOCATION OF PROPERTY: DATE RECEIVED (office use only) yes no 1. I am the owner of the above described property. yesoD 2. 1 am not the owner of the above described property, however, I certify that I have consent from owner to obtain a owner's name site evaluation by the Davie County Health Department for the purpose of determining the suitability for a ground absorption sewage treatment and disposal system. yes no 3. 1 hereby give consent to the authorized representative of the Davie County Health Department to enter upon the above described property and conduct all testing procedures as necessary to determine its suitability for a ground absorption sewage treatment and disposal system. DATE SIGNATURE 4. 1 hereby authorize the Davie County Health Department to release site evaluation results from the above described property to the following: Owner only _ Owners designated representative _Anyone requesting results — Only those listed below DATE SIGNATURE DCHD(11/84) ' DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation NAME DATE l/f/SfJ DATE EVALUATED lk ADDRESS PROPERTY SIZE y/�G PROPOSED FACIILTY LOCATION OF SITE % Gr'' Water Supply: On-Site Well Community Public Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3 4 Landscape 2osition L L Sloe Z — HORIZON I DEPTH Texture group Consistence Structure Mineralo HORIZON II DEPTH Texture group Consistence l �i Structure Mineralogy 1 HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION _ 717 LONG-TERM ACCEPTANCE RATE 1 SITE CLASSIFICATION: /l_ EVALUATED BY: 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 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 DCHD(01-901 ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■.■..■■.■■...■.■■■■■..■..■■..■■■■■■■■■■■■■.■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■..■■■.■.■..■.■tl..■■.■■■.1'■.■■.■■■■.■irk/■■.■■■■■■■..■■ MMMMM RMiiiiii ■■.....■■■■.■.....■■.■.■.■.I.■.■■.■...11■■./.■■.■■■■N31■■■■ ■■■■.■■■ ■■■■■■■■■.■■■■■■■■■■■■■■■■�l■■■■■ ■■.■A■■.■■.ti■■. ■■ ■■■. .■■..■. ■/■■/■■/■■/■■■■■■■■■■■■■.■■...■■■■.■■.■■■■■..■ ■._■■■.■■■ ■■.■.■ ■ ■■■■■■■■■■■■/■■■/■■■■■■■■■■■■■■■/■■■■■■■ii■i/■■iii■■ii■■�■■■■■■.■� ■■■■■■./■■■■■■■■.■■.■■■/■■■■■■■■■■■■.■■■■■■■■■■i=■■■/■■■ ■■■■■■■. 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