242 Ralph Ratledge Rd DAVIE COUNTY HEALTH DEPARTMENT 1&0.OU
- IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
` *NOTE:Issued in Compliance With Article II of G.S.Chapter 130a
Sanitary Sewage Systems � Permit Number
` , Name 11 �� E_ 1 t:. \I Date �" N2 7541
Location `iN
a LP
Subdivision NameLot No. Sec. or Block L.
Lot Size ASO k G Uo House Mobile Home Business -- Industry �
No. Bedrooms .No. Baths — - No. in Family - — Public Assembly Other
Garbage Disposal YES ❑ NO Secifications for stem: , 4
Auto Dish Washer . YES e,NO El 70�� QIc '✓ o c
Auto Wash Ma. l}�hjyle YES- NO ❑ O , . i t►
1
Type Water SuPPIY ---
4
*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.
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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
r
\ 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: E =
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 �&- Z ' //?// , Home Phon
) e '7
7 0,2 K Business Phone
2. Name on Permit if Different than Above
3. Application for: ❑General Evaluation Ur-S"e'ptic Tank Installation Permit
4. System to Serve: ❑ House VMobile Home. ❑ Place of Public Assembly
❑ Business ❑ Industry ❑ Other unknown
5. If house, mobile home: Subdivision Section Lot#
❑ Basement/Plumbing
No. of People Q_/'Basement/No Plumbing
No. of Bedrooms Lel Washing Machine
No. of Bathrooms ri 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: ❑ Public G?15rivate ❑ Community
8. Property Dimensions h Say X f; o� Sewage Disposal Contractor
9. Do you anticipate additions/expansion of the facilit 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 sub1ect to
revocation, if site plans or the intended use change. Effective October 1, 1989. _-
Directions to Property: O/ 1
40
�0 'uoj . cry, & a,,��� . � / �►�.�ca
Lm of
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This is to certify that the information provided is correct to the best of y knowledge, and I understand I am responsible for all charges
incurred froFn this a plication.
a a
DATE SIGNATURE
CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY
MUST CHECK ONE: ❑ 1. 1 OWN the property. ®-21.- 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 representativ o the Da�ie Cou Health Departm t toe ter upon bove described
property located in Davie County and owned by u�� ,r ,�o�
to conduct all testing procedures as necessary to determine said site suit ility for a ground absorpt on sewage treatment
and dispo al system.
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DATE SIGNATURE
DCHD(1/93)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
NAME �i��p`�� �. �1 _ DATE EVALUATED
ADDRESS `7 PROPERTY SIZE
PROPOSED FACIILTY \11;N \�'o VCICI-, LOCATION OF SITE - C
Water Supply: On-Site Well Community Public
Evaluation Byly� Auger Boring Pit Cut
FACTORS 1 2 3 4
Landscape position S S ._�r -S
Slope
HORIZON I DEPTH A X
Texture group C L C �-
Consistence —1-
Structure Q, I?, Q K k_
Mineralogy %') I '.\ !1
HORIZON II DEPTH LA 2 L4 2" �.Zn
Texture group
Consistence Y 1'
Structure \s, i�A CQN-- K
Mineralogy ' t i i i t
HORIZON III DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS 77 SS
RESTRICTIVE HORIZON —
SAPROLITE
CLASSIFICATION S .S m
LONG-TERM ACCEPTANCE RATE
SITE CLASSIFICATION: s EVALUATED BY:
LONG-TERM ACCEPTANCE RATE: ' Lq OTHER(S) PRESENT: 'N o Nsz
REMARKS: ! i. \"\
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/ft2
DCHD(01-901
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