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875 Rainbow Rd DAVIE COUNTY HEALTH DEPARTMENT "0 ' IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION 3 *NOTE:Issued in Compliance With Article 11 of G.SXhapter 130a Sanitary /Sewage Systems Permit Number Namef, �� 1Lf�F'�rf// Y_ sT`1 Date N0i J Location �5- '.. /r`}� 17�;'. 1�CJ,' ; r�rrr tt'/�' - s`� 057 Subdivision Name Lot No. Sec. or Block No. Lot Size House Mobile Home �''� Business __ Speculation No. Bedrooms No. Baths - No. in Family Garbage Disposal YES ❑ NO 0 Specifications for System: ,� Auto Dish Washer YES NO ❑ �ty `� Auto Wash Machine YES NO ❑ , 4 �` r Type Water Supply _— *This permit Void if sewage system described below\\nT installed within 5 years from date of issue. -` This permit is subject to revocation if site plans or the i t nded use change. �qI i 31 Y 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. or 1:00-1:30 P.M. on day of completion. Telephone Number: 704-634--5985. Final Installation Diagram: pjj` - _ System Installed by \ �� of e l!� 1oai 1 pdr Certificate of Completion Date' �-�-_�-��` u 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. w APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT ` Davie County Health Department Environmental Health Section �EO ��N a P. 0. Box 665 • _RECE Mockaville, NC 27028 1 . Application/Permit Requested By �'� / 1 1 U��S - Mailing Address '� �52�.t1��,YV �- �C /d (� Home Phone gqg '. ) 3 C1 Business Phone 2. Name on Permit if Different than Above 3. Property Owner if Different than Above 4. Application/Permit For : 0 General Evaluation VS/Tank Installation 5. System to Serve: House p�Flobile Home 0 Business L Industry u Other 0 Unknown 6. If house, mobile home: Subdivision Sec. Lott No. of People Dwelling Dimensions x 70 No. of Bedrooms _ � Basement/Plumbing No. of Bathrooms ` Basement/No Plumbing 0 Washing Machine (J' Dishwasher 0 Garbage Disposal 7. If business, industry, 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 8. Type of water supply: &4ublic 0 Private 0 Community 9. Property Dimensions 10. Sewage Disposal Contractor 11 . Do you anticipate additions/expansions of the facility this system is intended to serve? 0 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. 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. Date IV Si nature Directions to Property : MpGrV i�(� • 00 A; bn� Drv�'e wA�� DCHD (10-89) DAVIE COUNTY HEALTH DEPARTMENT ENVIRONMENTAL HEALTH SECTION SITE EVALUATION CONSENT FORM 1. Complete the form below and return to the Davie County Health Department. 2. Carefully follow the procedures as outlined in the enclosed "Information Bulletin." NOTE: THE ABOVE MUST BE COMPLETED BEFORE A SANITARIAN WILL BE ABLE TO BEGIN THE REQUESTED EVALUATION. DETACH HERE AND RETURN TO: Davie County Health Department, Environmental Health Section, P. O. Box 665, Mocksville, N.C. 27028 Davie County Health Department Environmental Health Section Site Evaluation Consent Form LOCATION OF PROPERTY: DATE RECEIVED ,5m;-14) /&;O�bop) (office use only) yes no 1. 1 am the owner of the above described property. yes no 2. 1 am not the owner of the above described property, however, I certify that I have consent from , owner to obtain a owner's name site evaluation by the Davie County Health Department for the purpose of determining the suitability for a ground absorption sewage treatment and disposal system. yes no 3. 1 hereby give consent to the authorized representative of the Davie County Health Department to enter upon the above described property and conduct all testing procedures as necessary to determine its suitability for a ground absorption sewage treatment and disposal system. - /8- 90 '13'I DATE —/U SIGNATU E 4. 1 hereby authorize the Davie County Health Department to release site evaluation res Its from the above described property to the following: Owner only Owners designated representative Anyone requesting results Only those listed below DATE SIGNATURE DCHD(11/84) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation A NAME + DATE EVALUATED ADDRESS �3 rI Jt 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 .0 1 Slope Z HORIZON I DEPTH 2 1 Texture group Z, z Z_ Consistence Structure Mineralo,gy HORIZON II DEPTH < _ 2e5 d Texture group Consistence Structure ThT 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 RAT OTHER(S) PRESENT: REMARKS: pC7, D/J e-" 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 Mi neraloity 1:1, 2:1, Mixed Notes Horizon depth t - In inches / p 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/ftz DCHD(01-901 ■■■■■■■■.iii.■.\\■■..■i■■i■■■■■■■■■H■■.i.l.■■■■■■■.■.■...■■■.■■ ■ ■■■■■■■■■■■■■■■■■■■►�e■■■■■■■■■■■..a■.■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■Nil.■■■.■■■■■■■■■.■■�■■■.■ ■■■■■■■■■■■■■..■■■■■ll.i.tl.■.1...■l..■ ■ll■■■■.■...■.■■ii.■.►�i■.■■■■■■■■■■■■■.■■■■■■■■■..ii■■.■...ilii.■■ ■■■i■■■.■■..■■i.■■■■■��■■■■l■■■■■■l■■■E■■■■■..■1....i■■■ilii.■■!ll■ ■.■■■/■■■■■■■.■■■■■■■■I/■■.■■■■■ ■■■■■■■.■■.■.■■...■lei■e■■tit■■■■ ■Eli..■■...■■■■■■i.■■.Ill■..■ii.■Ill.■■■.....■Nil.■....�l.i.i....■.■ ■■■■.■l■III,■�►�'..■■.■■■■..■■■.■■..■■■■■■■■■■■.....1....■■E■■ll..�.i■ ■■■■.■■■1II ►^t7J1�■■■■■e■rs�.■■e■.■...�■■■■■e■.■.■■.■■■■/■111f■■■■■■■ Nee ■■■.■■■■ga�N■■■M.■■■■■ri■■■■■Nee■■ ..■■■■■■■■.■■.■.ee■e�■■.■■■■■■■■ ■■■■■■■.■■■■■■■■■■■■eye■.■■■■■■■■■■■■■e■■■■/M■■.■..ME/■■■.■M■■EN/�e ■.■■■■■■■..■E■■■■.■.11.■■■■■■■■.■■■.■■.■ilE■■■■■li...i.■Ill..■l.li. ■■.■.■E■■■...■■M■■�%■■■■■.■.■■■■ ■.■.1..■■E■.H..■■.[ol...■■l.■■■■ 1■Illi.■■■..1.■■.■rI.■.i..■.........■■■...■.■.....■■.■.�/..■■■..■..■ .....e.........................■■......................■. e■■■■■■■ ■.■■..■....�il.l.■■■■i...■..1.■■■ill■l...E■..1.■.1..■l..M.11■....■■ �oiiiii�iiiiii�iiiiii�iiiiii�iiiiii�oiiiii�iiiiii■�iiiiiii� ■■■��./■■■.■■■..■■i■■■■■.■■....■■......■Bill■■■.ill■.■........11■ ■C.■o..Ill■■■..■■i■■■■■■.■.■■■■.■..i.E■E.....■■■..■■■...■�■■■.■■l■ ■■■■■■■■■.■N..■■M■M.■■■■■■.■M■■.■■■...■.. .......1..■...1 ■■M■■.■■ ...................................... . .......... .............. ■.E.ill.■■■■■l..■..■■■.........■ll■■..■l■l..11■ ■Ill■■l. ■...■■.l ■■■.■■■.11■■.■■....iii.■■l.■■...■■■1...■..1.■.■�=■■■ll..�l....... ■■.■....■■...■....■■...■■.....■■ ■.M■■■...■....1■.....■■■■ME■.■el iiiiiiE iii■iiiiiii�iiiiiiiiiiiiMMMMMNiiiii iii■MMMMSMiiiiiiN NONEi ■■■■■■e/■■■■■■■■■■■/■■■■/.■■■.■■ ■■M■■■M=■.■■M■.■.■■/■./■.■■■.■■■ ■■■■M■e■■■/■■■■..■■■■■■■..M■M■■e■.E/■M■.s ■■NEEM.■■■■■e■■ ■.■■■/■. ■EMMEMEM.MMM■■MME■■■■■■■■ ■■■■■■■■■■■./■■�.■■...■■■■■E■..EMM■M■■ME ■■■■■■■■■MM■M■ee■■■■e■■■■■■.■M.■ ■e.■■.■■■.N■■EHM■.■■■■■M■E■..e■ �iiiiiiiiiiiiiiiiiiiiiiiiiiiiiii.■iiiii��iiiiiiiiiiiiiiiiiiiiiiiii s a� avie CountyHealth Department L �. wnvironmental Health Section "< P.O. Box 848r , ti�N r'. r� N4A�A, 210 Hospital Street ,-i N"N' h j�RON�r�GOJ;� Courier# : 09-40-06 V 4- " oP' Mocksville,NC 27028 , x± y. Plione:(3 -753-6780 Fay:(336) -753-1680 ON-SITE WASTEWATER CERTIFICATION FOR DWELLING (Check One) Replacement Remodeling Reconnection x Name: C► 1 'e I f , C(_�; Phone Number. �J (Home) Mailing`Address: a 5 I (' L !S 1 9 7 _(Work) t NUanee /UC d9.L O Detailed Directions To Site: HLJL1 r S S -k) RQ 1 o U o O Ad . Q�'4e r' y0LA pqrj Qg reen e wJ -hcr 4.5 k e Se eo n d i U an n a 1 e {�-�. creep �Q lox Property Address: on +4c r 1/t/ S.de Please Fill In The Following Information About The EXISTING Facility: Name System Installed Under: TA Type Of Facility: SM/),ff Date System Installed(Month/Date/Year): MtF - 7 Number Of Bedrooms: Number Of People: Is The Facility Currently Vacant? Yes If Yes,For How Long? Any Known Problems? Yes 0 If Yes,Explain: Please Fill In The Following Information About The NEW Facility: Type Of Facility:_ 46 use Number Of Bedrooms: � Number of People Pool Size: A A Garage Size: Other: (Requested By: AA Date Requested: f b lie J IU (Sign tore) 44 For Environmental Health Office Use Only 7A7pp�rovcdisapproved Comments: Environmental Health Specialist Date: ,017_ZJ2Q/0 *The signing of this form by the Environmental Health qt8tYis in no way intended,'nor should be taken as a guarantee (extended or limited)that the on-site wastewater system will function properly for any given period of time. Payment: Cash Chec Money Order # 2, Amount:$ 100.60 ate: 1017--0110 G�EP Paid By: �f5 Received By: kccount#: 12y( Invoice#: V10