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397 Potts Rd (2) DAVIE COUNTY HEALTH DEPARTMENT { r _ IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION' *NOTE:Issued in Compliance With Article I I of G.S.Chapter 130a Sanit7ary Sewage Systems Permit Number Name _� � �\ — Date / r I y N2 7789 Location _ — — Su ' sion Name Lot No. Sec. or Block No. Lot Size cti 5-,-7-a = House Mobile Home — Business -- Industry No. Bedrooms —.No. Baths _ — No. in Family — Public Assembly Other Garbage Disposal YES [!a/ NO ❑ Specifications for System: p Auto Dish Washer YES (p/ NO E] 1 or-3 - �]1�.. � ' U_ _ +, Auto Wash Ma thine YES [p/ NO ❑ ' } ILI t} Type Water Supply _ Vo � — --___— *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. 1 71 Y a d ` J hut.; 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 da No u s a P •� / 1 • JCr r .f,. fu y Certificate`of Completion Date 'The signing of this certifi to all in icate that the system described above has been installed in compliance with the standards set forth in I a move r gulation, but shall in NO way be taken as a gua antee that the system will function * satisfactorily for any give6 period of t me. APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT Davie County Health Department Environmental Health Section P. O. Box 665 Mocksville, NC 27028 1. Application/Permit Requested By Mailing Address �q� Y��__\\� A Home Phone DACE Business Phone S(1,MZ 2. Name on Permit if Different than Above J 3. Application for: ❑General Evaluation l(Septic Tank Installation Permit 4. System to Serve: IZHouse ❑ Mobile Home ❑ Place of Public Assembly ❑ Business ❑ Industry ❑ Other ❑ Unknown 5. If house, mobile home: Subdivision Section WLot# Basement/Plumbing No. of People ❑ Basement/No Plumbing No. of Bedrooms E�Washing Machine No. of Bathrooms (2 Dishwasher Dwelling Dimensions 3O I4/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 ErPrivate ❑ Community 8. Property Dimensions Sewage Disposal Contractor / 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes [Z/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: This is to certify that the information provided is correct to the best of my knowledge, a I understand I am responsible for all charges incurr d from this application. DATE SIdhATURE 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 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 absorption sewage treatment and disposal system. DATE SIGNATURE DCHD(1193) ►' DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation y �{ NAME LA \\�c� , `" 1r DATE EVALUATED _ ADDRESS ►�te'''a PROPERTY SIZEp 9 PROPOSED FACIILTY ��°�" LOCATION OF SITE ____ �r>S+` `i�� h Water Supply: On-Site Well Community Public Evaluation B&LZ _ Auger Boring Pit Cut FACTORS 1 2 3 4 Landscape position S S .S ,..-.S Slope R -lb lb" -1ST HORIZON I DEPTH Texture group Consistence _ Structure Mineralogy HORIZON II DEPTH Z \� Texture group Q Consistence Structure w \ Mineralogy HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS S5 SIS RESTRICTIVE HORIZON SAPROLITE — CLASSIFICATION •S. • S. .S• LONG-TERM ACCEPTANCE RATE Ls SITE CLASSIFICATION: R EVALUATED BY: LONG-TERM ACCEPTANCE RATE: �� OTHER(S) PRESENT: \` REMARKS: S�i�A 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 Mineraloey 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 ■..■■...■■■..■..■.■■.....■■■■■.■.■.■■■.■■......■..■...■■■■ ■NEON.■ ■■■■.iE.■■.E■../..EEO..■.E.■./.■�.■/■.■■....■..■...■■■.■...■■■... .................................................................. ■■..■........../►1►10..■■.■..■./.■ ■....■..■ NEON../NOON../NOON ■■E ■/■.......■■■■.lay'/J■■■.■■■..■■...�3.NOON■...C....../NEON■./NONE■./■ ■.....■....■.■..■■■■■■.■■...■■...■■■.■■.■■..■.■.■./.. ■ENNEN.■.■ ■ ■/NONE■■/■E■...i.E....■■■E..■.O. ■.■■■.■■......■...■■....■■.....■ /.■■..■■.■...■.■.....■.■.■■■■..■..e..■■■■e..e■.e.■■■.■..■■■mom■.■ ■/......■.■.■■i■■is��!�■■■.■■■......■■.■■.....■■.....■.■■ NOON■./■ .�iiiiiiC■�=iiiiiiC.�';iiiiiC.miiiiii�CCC� ■.■..■...■.■■■■�.■■.■1�■.■■��■..■11■.■■■■.■■ NONE.■. n■.■■..■■.■...■ ■■■..■..■_■,■■.■l�O...EI/NOON/l..■.11.■■..■ ME No ■�■■■■..■.■■..E■ ...■..■C!�1I\■■■NEON..■I/\i/J..'1.■.■►/.■■■■■ ■OEN.■ ■ ■E■■E■.■..E.E■ CCC■�CCCI�iiilC■EiC�Aiiiii■�CC C■iiI t■■CGCG C..iCCCC.�iC CCCCCME manCCCCC CCCCCCCCCC,iiC■iiiieiCriin�e;�C/CCCCC■CCCCCCCCCCCC■ CCCi.CCCCCCCCCCC ■.■■.■■■■■f1■■...■.■■'■■■Ii�r■./,..e.■■C■■■.■■e.=eeeC eeeeee■■■e■e..e■ ■■.....■.■■■iii:i��•/■/../1@rJ�,■■��■■s■e■■.■CCeCCCeC/�=CCCCCCCimummommm fCCCCCCCo ■....■u■.■..■■.■,�elnl►er�.■.■ri..■■� ■■u. 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