580 Deadmon Rd ell
DAVIE COUNTY HEALTH DEPARTMENT Q
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
�- ,
'.NOTE;,Issued in Compliance With Article 11 of G.S.Chapter 130a
,.SanitarySewage Systems JrJ,"y lJr -c.�.1� /. Permit Number
—N ry /� �, Date . N2 8171
Location
Subdivision Name Lot No. Sec. or Block No.
Lot Size _,��'r — House — Mobile Home --_— Business �Industry
No. Bedrooms — —Zf_f.No, Baths --J-- No. in Family '— Public Assembly Other
Garbage Disposal YES ❑ NO Specifications for S stem:
Auto Dish Washer YES ❑ NO
Auto Wash Ma^hine YES, ❑ ,.NO
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: YOUR SEPTIC SYSTEM CONTRACTOR MUST SEE THIS PERMIT/LAYOUT BEFORE INSTALLING THIS
SYSTEM.
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 Installe by — w
Certificate of Completion I ___ 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.
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site.Evaluation
NAME P0_JQ.yrZ,(, L DATE EVALUATED
ADDRESS PROPERTY SIZE 164-
PROPOSED
6 PROPOSED FACIILTYLOCATION OF SITE S(/ECJ'�lJd7�(L
Water Supply: On-Site Well _ Community Public- Z,---,*'
Evaluation By: Auger Boring , i Pit Cut
FACTORS 1 1 2 3 4
Landscape position 2-
Slope % —
HORIZON I DEPTH Aly,411 J -o
Texture Sroup
Consistence
Structure
Mineralogy
HORIZON II DEPTH
Texture group
Consistence
Structure Sit/
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
J:�
SITE CLASSIFICATION: EVALUATED BY: li/J
LANG-TERM ACCEPTANCE RATE: i 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-V+:!.-y 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
3C--Single grain M-Massive CR-Crumb GR-Granular ABK-Angular blocky
SBK-Subangular blocky PL-Platy PR-Prismatic
Mineraloay
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
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APPLt F FOR SITE EVALUATION/IMPROVEMENTS PEF IR @ L5 ow E r
ti —
Davie County Health Department
Environmental Health Section 23
P. O. Box 665
Mocksville, NC 27028
1. Application/Permit Requested B
Mailing Address Home Phone p, " c•�
-e. C. Business Phone `ice^ 1S cam "
2. Name on Permit if Different than Above
3. Application for: ❑General Evaluation (d-Septic Tank Installation Permit
4. System to Serve: ❑ House El Mobile Home El 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 ❑ 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: WP/ublic ❑ Private ❑ Community
8. Property Dimensions Sewage Disposal Contractor
9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ 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:
C�J- rT\) r
y
This is to certify that the information provided is correct to the best of my knowledge, and I understand I am responsible for all charges
incurred from this application.
��3--�fi
k4j
DATE SIGNATURE
CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBE ROPERTY
MUST CHECK ONE: ❑ 1. 1 OWN the property. 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 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 bsorption sewage treatment
andQd�.sposal system.
DATE SIGNATURE
DCHD(1193)
a