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P6975 Pine Ridge Rd Wr~s��"�,*��m/'r,��`�� / _~�` �W�� K��' �� NW� �v��""" ~~~~�°��=~~~.~' - IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION ^��TE�1a�um�in�on�o|�m�mV��h��Um�� 1@Oa ' Sp,nitary Sewage Systems Permit Number Name' N2 6975 Date Location Subdivision Name Lot No. Sec. or Block No Lot Size X2 House Mobile Home __-��_--- Business --- Speculation No. Bedrooms - No. Baths - No. in Fmmi|y__-_-___ ,�� Garbage Disposal YES [] NO uSpecifications for System: Auto DishVVashar YES NO [] Auto Wash Ma:hine YES NO Type Water Supply ' *This permit Void ifsewage system described below is not installed within 6years from date of issue. This permit is subject to revocation if site plans or the intended use change. , ` �J - -- ~ ./~ ' . / Improvements permit by *Contact a representative of the Davie County Health Department for final inspection of this system between 8:30- 30 letion. Telephone Number 704-634-5985. ' Final Installation Diagram: System Installed by f � ell?T . ' ' y ' ' Certificate ofCompletion XDate -^ 'The signing of this certificate ohm|| 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 oftime. .\ APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT ' ' *' ll' Davie County Health Department Environmental Health Section NQv 55 992 P. O. Box 665 Mocksville, NC 27028 - ------ 1. Application/Permit Requested By ;7 D'� Mailing Address �' � �16 X oZi� ,i D��'S L'-A0 1- 2 Home Phone �g �� Business Phone 2. Name on Permit if Different than Above / 3. Application/Permit for: /General Evaluation eSeptic Tank Installation 4. System to Serve: ❑ House 2Mobile 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 2 ❑ Washing Machine No. of Bathrooms ❑ Dishwasher t 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 ❑ Private ❑ Community 8. Property Dimensions ` �`� a '�� Sewage Disposal Contractor 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes a 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: 'Pre S ec?io-^' Hod'Sia �� /di iF 7` 0- 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. ZZ— 2 L/-" 9 Z 91:;�*h DATE SIGNATURE CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY [andd ECK ONE: l�1. 1 OWN the property. ❑ 2. 1 DO NOT OWN the property. ked Box #2, the rest of this form MUST be completed by the owner or a person authorized by the owner: ve consent to the authorized representative oft Davie C unty Health Department to enter upon above described cated in Davie County and owned by i all testing procedures as necessary to determi a said site's suitability for a ground absorption sewage treatment al system. DATE SIGNATURE DCHD(12-90) •,; . DAVIE COUNTY HEALTH DEPARTMENT b Environmental Health Section Soil/Site Evaluation NAME DATE EVALUATED ADDRESS PROPERTY SIZE PROPOSED FACIILTY - LOCATION OF SITE Water Supply: On-Site Well Community Public Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3 4 Landscape position L L_ c_Slope % HORIZON I DEPTH Texture group Consistence Structure MineralogX HORIZON II DEPTH 7 /— 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: 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/fu DCHD(01-901 ■.■wee.■■■■.■w■■!!lw..■■■.w■■e.■■■■■/l...■■/....■//..■■■s/.■■.■■■■ ■■.■■■..■■..■■■/.■.■■■/a■...■■■e■..■/.■■.■■■■..■■■■■■■■■.i■■■well■ mom ■■■■■■■■.■■■■■■.■..■■■.■Asn■■!.■■�■..■■e►•■..■■..■■e■■■.■e/■■.■.■/■ MINEMMIMEMNON MENNEN MEMOMENNENMINEEMEME�� .........................■.................... ■e.e■.!.!■ ■■!■■..■ iiiiiii■viii■iiiiiii�iiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiii■�iiiii ........................................... ..................... ................................ ................................ ■■■■/■■■■■■■■■■■■■■.■■■■■■■■■■■■■■■■■■■.■■■■■■■■■■■■■■■■■■■■e■■■■■ ■■■■/.■!.!!■■!■■s■/!■■■■■■■e■■■ee.■■■■■■■■!■■■■■■.lea■■■.■!■■w...■ iiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiu■iiiii��iiiiiiiiiiiiisiiiiiiiiiii