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212 Morrison Rd + DAVIE COUNTY HEALTH DEPARTMENT P IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION 'NOTE:Issued in Compliance With Article II of G.S.Chapter 130a Sanitary Sewage Systems y _ Permit Number Name ,.� k �c, t,.— Date �n w .� _ . 1` E No 8 0 5 9 �� Location t �. \ t a r, ;,c_ �3 -• �` Y ` Y � t.:.� 1 ".� i.�Y'+ �,t T .:��'..,.., \ ),"R�t� �. -c•,, ,�`•_,f CSi�+ `i.c.`,,? ,ti 1 t, k-� ,ti a,"?t•F �"r:;�.. Subdivision Name Lot No. Sec. or Block No. F A Lot Size " House — Mobile Home —_ Business __ Industry No. Bedrooms -`' _.No. Baths — — No. in Family h a Public Assembly Other Garbage Disposal YES p NO p, Specifications for System: Auto Dish Washer YES [] NO p� J bo() Auto Wash Ma^hine YES [Q NO O Type Water Supply N, '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.,; YOUR SEPTIC SYSTEM CONTRACTOR MUST SEE THIS PERMITOYOUT BEFORE INSTALLING THIS SYSTEM. i i j 1 r Improvements permit.by — *Contact a representative of the Davie County Health Depment for final Inspection of this system between 8:30-9:30 A.M., 1:00.1:30 P.M. or 4::0-5:00 P.M.on day of completion.Tele one Number: 704-634-5985. Final Installation Diagram: Sy tem Installed by \` I-7 �n/5 0 \t 1, J- Certificate of 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 satisfactorily for any given period of time. r APPLICATION FOR SITE EVALUATION/IMPROVEMENTS P �r Davie County Health Department Environmental Health Section JUN ^ 6 P. O. Box 665 Mocksville, NC 27028 1. Application/Permit Requested By C,LL �-� ,40 i® 6)4 t5 Mailing Address / 1�0�t.C��.�D�✓ Home Phone 7 q2 -1-Irl 6 C k��, �L Business Phone G 3�(-1-�Wo 2. Name on Permit if Different than Above 3. Application for: ❑General Evaluation .`Septic Tank Installation Permit 4. System to Serve: ❑ House Z'Mobile Home ❑ Place of Public Assembly ❑ Business ❑ Industry ❑ Other ❑ Unknown 5. If house, mobile home: Subdivision Section Lot # ❑ Basement/Plumbing No. of People ❑ Basement/No Plumbing No. of Bedrooms °Z 93"Washing Machine No. of Bathrooms ❑ Dishwasher Dwelling Dimensions fit: 15 ❑ 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: 2 Public ❑ Private ❑ Community 8. Property Dimensions c iLerr, Sewage Disposal Contractor 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ,T Yes ❑ 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: —I&/- 4/ C9 N r'� o- This is to certify that the information provided is correct to the best of my k d e, and I understand I am responsible for all charges incurred from this application. DATE SIGNATURE CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY 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 fhe Dave County Health Department to enter upon above described property located in Davie County and owned by A ,v mac. -,Io c to conduct all testing procedures as necessary to determine said site's suitability f r a ground absorption sewage treatment and disposal system. DATE SIGNATURE DCHD'(1193) DAVIE COUNTY HEALTH DEPARTMENT • ' �, Environmental Health Section Soil/Site Evaluation NAME w DATE EVALUATED ADDRESS Q'«^e PROPERTY SIZE PROPOSED FACIILTY • �� '`e LOCATION OF SITE Water Supply: On-Site Well , / _ Community Public Evaluation By:�,(, Auger Boring V Pit Cut FACTORS 1 2 3 4 Landscape position S S S Sloe Z Ci � v - `' O -$ o O HORIZON I DEPTHt �I, Texture group C. t- Consistence Structure '�-- MineralogX HORIZON II DEPTH Texture grouptv c Consistence N StructureMineralogy HORIZON III DEPTH Texture grou2 Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS 515 S SS RESTRICTIVE HORIZON — — — SAPROLITE — — CLASSIFICATION C12 - ,S LONG-TERM ACCEPTANCE RATE , SITE CLASSIFICATION: Q •� 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 <.-lay 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 ructure e grain M-Massive CR-Crumb GR-Granular ABK-Angular blocky alar blocky PL-Platy PR-Prismatic kness and inches from land surface (unsuitable) om land surface to free water or inches from land surface to soil colors le), PS(provisionally suitable), U(unsuitable) ptance rate - gal/day/ft2 ■...■.■.■■....■../■.■.■.■.■■■■.■■■.■..............■...!■.....Mumma ■■■■.......■■.■......■.■...■■.M■...M..M.■. ./■...■■ ...u....m■■m■ ■.........■m!■■■■......l...■■■■■■■■m......E.m..MR■■aama.MMMm■■a■■■ ■..■.....O..O......./....■■ ■...l.OE..■ ■.■.m.. 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