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888 Ratledge Rd DAVIIE COUNTY HEALTH DEPARTMENT IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION *NOTE:Issued in Compliance With Article II of G.S.Chapter 130a anitary Sewage Systems Permit Number Name ��i^�D7 ..%�'QSt.��/ �� D ' No 7 4 0 5 Location ��r°1.f' � - PQM iJ✓,% ��i r/ r/ y r Subdivision Name Lot No. Sec. or Block No. Lot Size �� House &---' Mobile Home Business _— Industry No. Bedrooms No. Baths :X1 _ No. in Family _— Public Assembly Other Garbage Disposal YES Q NO g-- Specifications for System: Auto Dish Washer YES �} NO Q Auto Wash Ma thine YES [tj NO Q Type Water Supply 'This permit Void if sewage system described below is not installe within ars from date of issue. This permit is subject to revocation if site plans or the intended use c ge. _A,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 0 4d Certificate of Completion A Lltd 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: r DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation NAME ��//iG° DATE EVALUATED 2.4z ADDRESS PROPERTY SIZE PROPOSED FACIILTY A�Lr LOCATION OF SITE Water Supply: On-Site Well k1_11, Community Public Evaluation By: Auger Boring k� Pit Cut FACTORS 3 4 Landscape position Slope % X/ HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH 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: � , �7 EVALUATED BY: Q �� LONG-TERM ACCEPTA RA E: 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 fine 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 Mineralolzy 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 ■■■■■■■■■■t■■t■t■■■■■■■■tt■e■t■■�t/■ttt■■tt■et/ttttettttt■//■.■/■ ........................... ...................................... ■.e.e.■■e■eee..■■■e..tt■e.ee■■■.�.■...■■.■.■.■■..■■......■...■.■■ ■.......■.............../.■.■■//�..■.O.■..�..e..■..O..OM....e E.. ■e.eM.........M..eM.ee..el�■eeett ..■tie... .r;■.e..eeee..Ee.e..e.. ■..■■.■.■E.■..0.■■..Oe■..■.i�.■....O...I■eO.■E■■■..0.■.■■.�e..MO■■ iiiiiiiiiiiiiiiii'■i■iiiiiiiiii'i'�■'i�■ice i�.iiiiiii.�iiiie.iiiii'.i ■.■...■.■eM..e■...■.■..■M.■■....�i.....■.'fie.■.■.N.■..■..0..■.■.... MENNENMENNEN ' iii�i .�MENEM IMMMMMUMWMNMMMMMM ■..e...■.■■■...■.■■...■■.■■■�.■■■■■.■■■ .1■�■■■■.■ ■.I.■■.■MMMMMM■■■ e!■tie■■■etMt.Ottei■EEOC/.tMl...te/e.■■ .■eM.M mom e.t.t..e........■i,.M..�......i��_e.�.�e�... ■...■■■■■M.■.e..■I,M..■■.....e■..ii.�e.iNMEM■.. ■■■■.■■u■. .O.■ ':::::: ■tetetee■e.et.■■t■tOtet�le.e.eeMEN" MEMMOIMMEIsm O ....■... .■. ■.■./1!■t■■�.■.............■�MEN.�■ ■■ OM■■E■MOMME ■■ .......................1...............�..■ MMMI MMMMMNMM uMM::' ■...■t■■■...0..0..1.....10■■M....l...EN ■.■ ■■...ME...EE.M...■.M..■........■ ..■...0 ■...■..ENe.e■.M.■M e.E! MOM IMMMMMMMMMMMNMMMMMM KNOMEMEMMEMEMOMMON tttttttttt.tt.tt.t��t /t�itttttttt ttttt.tttetteetMteteteieettttet■ ■.....■e..e.l.■O.■011...��.......■■M...■■OM..■■■.■■.■...■■.■Oe■■■.■■ ■■tttttttt\ttt�t■■tl��■��tt■�!•�t�t!•tt■eettMtttttette/tititeitt■ ■.■........e■ti.iE.lute.l\ttti.■t■t.■ttie.e..Elft■tttt.tit/tt.tttt■ ■.■..■..■.e..e.■Mee■eeMei�■eee.eee....e.eee...e.....Me.MEe■......E■ ■.■■=.■.■a■.■..e.......■■...■e............■.■....M.O.s...........■ ■/.■ ■.■tttN■tOit.t.tt.■■MteOMe�.■te.........■e■.....e.■.e..■.M■ APPLICATION FOR SITE EVALUATIONAMPROVEMENTS PERM -- - •. Davie County Health Department 1 , 'as„OrD Environmental Health Section DEC Z 693 P. O. Box 665 Mocksville, NC 27028 - --- -- -- 1. Application/Permit Requested�dfy is Lt I ej -- Mailing Address�� / -3 3 7�—j D /lsy i �� ,C ' Home Phone �v3y Business Phone 37-�L3;23 2. Name on Permit if Different than Above 3. Application for: ❑General Evaluation Septic Tank Installation Permit 4. System to Serve: VHouse ❑ Mobile 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 ❑ Washing Machine No. of Bathrooms ❑ Dishwasher 7- 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 f j q'c�rel fjd Private ❑ Community 8. Property Dimensions Sewage Disposal Contractor 9. Do you anticipate additions/expansion of the facility this.sytem is intended to serve? ❑ Yes l" 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: L 1�o (f–)v rc- D a v L&-p d n v h& 0l, ),5� j n e A k4- p� /edj e 4950� 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. A�� L21- :2/- %3 DATE SIGN RE `rnR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY ❑ 1. 1 OWN the property. ❑ 2. 1 DO NOT OWN the property. `arm MUST be completed by the owner or a person authorized by the owner: resentative of the Davie County Health Department to enter upon above described d by sary to determine said site's suitability for a ground absorption sewage treatment r SIGNATURE