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397 Pleasant Acre Drof -i W~ DAVIE COUNTY HEALTH DEPARTMENT r IMPROVEMENTS PERMIT AND `CERTIFICATE OF COMPLETION *NOTE: Issued in Compliance With Article II of G.S. Chapter 130a Sanitary Sewage Systems Permit -t' Number Name �' ^rte /� < toi��T N2 7 U 6 4 LocationG�! �f` ✓ �_ �r %^ __ .LCL" Subdivision Name Lot No. Sec. or Block No. Lot Size— House Mobile Home _�'`� Business -- Industry No. Bedrooms e-2 —.No. Baths --/-- No. in Family _ Z Public Assembly Other Garbage Disposal Auto Dish Washer YES ❑ NO YES NO 21 ❑ Specifications for System: // �r%'7�v 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. G 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., 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 =1 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. APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT �! r Davie County Health Department ( %i �® S(J Environmental Health Section �lJ� P. O. Box 665 Jul. � � �} Mocksville, NC 27028 1. Application/Permit RequeAteo-§y I �' l ' e1 i e(�,t _ A Mailing Address 2. Name on Permit if Different than Above 3. Application for: 4. System to Serve: ❑ Business Business Phone 9()y CSJ36) r15M ❑ General Evaluation Xseptic Tank Installation Permit ❑ House Mobile Home ❑ Industry ❑ Other 5. If house, mobile home: Subdivision No. of People No. of Bedrooms 02 No. of Bathrooms Dwelling Dimensions 6. If business, industry, place of public assembly, other: Specify type No. of People Served No. of Commodes No. of Lavatories No. of Sinks No. of Urinals No. of Water Coolers ❑ Place of Public Assembly ❑ Unknown Section Lot # ❑ Basement/Plumbing ❑ Basement/No Plumbing ❑ Washing Machine ❑ Dishwasher ❑ Garbage Disposal No. of Showers Water Usage Figures 7. Type of water supply: ❑ Public / /! ? a�> ❑ Private 8. Property Dimensions d cru Sewage Disposal Contractor 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes ❑ No If yes, what type? ❑ Community *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: / � � iP . tV 1 c..� r ✓� /2 �f vn 77tp vf Tarn fen J' ?1h4reS ) .7� r7�Y/t�Cc�► A- �U f " &0/ ,A4e sec p6r<:2sofl7(- acre- pr - /J2 - fYQ r 'Ar d vt �✓�ec1P��Y �IOC�{�c� �27�lPP� 02 ,710 vInd l/fr a`r l Q /cz r r,� e ✓�� 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 tF lication. /� , DATE SIGNATVAE CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY MUST CHECK ONE: ❑ 1. 1 OWN the property. V-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 represent 've of the Davi 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 suitattlity for a ground absorption sewage treatment arn-d� disposal system. DATE SIGNATUFIE DCHD (1193) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section t� Soil/Site Evaluation r NAME ADDRESS PROPOSED FACIILTY, Water Supply: On -Site Well DATE EVALUATED PROPERTY SIZE LOCATION OF SITE Community Public Evaluation By: Auger Boring Lf:"!: Pit Cut FACTORS 1 2 3 4 Landscape position Slope % HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH h *' Texture group Consistence T77- Structure 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: Zr LONG-TERM ACCEPTANCE RATE: . / REMARKS: DCHD(01-901 EVALUATED BY: A/� </ OTHER(S) PRESENT: 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-Va.>y 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 3C -Single grain M -Massive CR -Crumb GR -Granular ABK-Angular blocky SBK-Subangular blocky PL -Platy PR -Prismatic Mi neraloity 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 ■■��■�■��■��■��■��■��■��■��■ ■�� ■Y■ ■��■�■��■■��■��n��■ ■■�■��\��■��■�� ■��■�r��■■ ■��■��■��■��■��\■��■��■��■��V/��■ ■■�■��■■��■��■��■��■�\��e\■ ■��\��■��/�■■��v■ ■��■��■��■��■��■■��■��■�r��■��■ ■��■E��■��■��/�■�/��■��■ ■��■�/��■�/�■��■\��■ ■��\��■��■��■�� ■��■��■��■�■��■ ■��■�� ■��\��■�■��■ ■/��■��■��■��■�� ■��■��■��■��■ ��■��■��r��■��■ ■�■��■��■��■��■�\�� \�� ■��■ ■��■��■■ ■��■��\� �� ■■ ■��■��■��■��■�■��■ ■��\�■��■��■��\��■�■��■ ■�■��■��■�■ ■�■��■��■■��\��■��/� ■��■i��■ ■��■��■��■��■�■��■ ■��■��e��■��_��■�■ ■��■��■��■��■��■��■�■��■�■��■ ■�■�� ■��■■�■ ��■u�� ■■■■■■■■■■■■■■■■■■■■■■■s■■■■■■■■■■_■■■■■■■■■■.■■■■■■�■■■■■■■■■■■�■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■ ■■■ ::::::::::::::::::::::::�:::::�3:::::::::5::::::::::::::::�_::: ........■......■..........................■.......■■. ...■...■.■■ ................................................■.■.._...■...... � .................................................. .............�. .....■..■.........................................C............... ..................................................■............... ........■........................................■......._........ ................................�....................... ........ ■��■��■��■��■��■�� ■��■��■��■ ■�■��■��n��ww��e_��.-■��■�� ■�� ■��■��■��■�� ■�■�� iiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiii�iiiiii iiiiiiiii�=�i�i�uiiiiii iiiiii�iiiiiii��iiiiiiii��iiiiiiii�iiiii=i�iiiiiiui�ii=i�iiiiiiii�ii �iiiiii�iiiiii�iiiiiii��iiiiiii�iiiiii��iiiiii i�iii?��iiiii ' ■��■��_�� ......................................�.........■........�........ ■��N��l:==��ii�:�-==== ■� ■�� ...................................... .:E....... :�.....�........ ...................................... ...... . ..... ........ :::::'.:::::::::::::��C:�:::::":::: :.::'.C'.CC� ::C:C::�=::�::� ::::::CC::::::::CC::CC:CCC:::::C:::::��:'C::: :C::::::::s.... .... ■��■��ur►��■�� ■ y�a� �� ■ ■��■��■��ri�■��■ ��r��n�� ■�� ■��rA��■��a��n ��_ ��■��■�� :::::::::�:'.::':::�::�::C'.:'.�::':::�': �: ' :��C:'.�::C::C:: �=��u�= ■��■��■��■�■��■■��■rs_ �■�� ■� ��u■��■�� ■�■��u��n ��i u ��inN�� ■�� ■�� ■��1�►'��N �� :::_:::��::C:::::"�::::::::::::::::::��... .. .C......�.�.. .... .. ....�... .. ..................................... ... ....CC.... .......... ......................................'�...�C...........C.....�... ................................�......._................... .... ................................ ....... ........................ ■��H�� //��n�� ■��■��■��■ N �N�u��■ ��■�\��N��u■�■�� h�� N�� .......... ..............�.............._ � ......................... .............. ........................ .................... ............................................. ....................C...........�.....■.......................... ................................ ................................ ■��v��v��i��N��■ ■��/��■ ��/� ■��■\��■��■��■ ■��■��■��■��\��v��/��■ ■��\��A��/��■ ■��■■��■��\��■��■��\�■ ■��■ ��H��■��■��■��■��/��■ ■\�■/��■��■�� ■��■ ■��/��U��■ ��/�