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223 Maplewood Ln DAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENTS. PERMIT AND CERTIFICATE OF COMPLETION *NOTE:Issued in Compliance With rt'c I I��aaf G.S.Chapter 130a AanitarySewage ystewar�'G y Permit Number Name SCf �•� ,��1 ,�� -- Date . N2 7699 Location Aa \4W le Subdivisio Nam Lot No. Sec. or Block No. Lot Sized% House �- Mobile Home Business Industry No. Bedrooms c2- - No. Baths _ No. in Family _ Public Assembly Other Garbage Disposal YES NO ❑ 'Specifications for System: Auto Dish Washer YES NO ❑ Auto Wash Ma^hine YES NO ❑ � � Type Water Supply _ A"/ '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. :.-.. I 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 _ se; ,i i F Certificate of Completion tate '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. LICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT 4- ;S.", Davie County Health Department IDr Environmental Health Section P. O. Box 665 Mocksville, NC 27028 hwe, 1. Application/Permit Requested By �i�o,a bile ��,'�dLi _ ��r c ,✓' Mailing Address //9 A✓.e fl0/ �o w� �,� � Home Phone ,Al ce' Al,' 0a 7,906 / Business Phone 9�� 2. Name on Permit if Different than Above__- �cl,-e✓ � 67u lel 3. Application for: ❑General Evaluation Septic Tank Installation Permit 4. System to Serve: House ❑ Mobile Home ❑ Place of Public Assembly ❑ Business ❑ Industry ❑ Other ❑ Unknown 5. If house, mobile home: Subdivision Section Lot # ❑ Basement/Plumbing No.of People Z A Basement/No Plumbing No. of Bedrooms ,Er Washing Machine No. of Bathrooms dishwasher Dwelling Dimensions 30 R 5rb Pr-parbage 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 ,'Private r J,// ❑ Community 8. Property Dimensions a/a t Sewage Disposal Contractor 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes 25-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: io / / �/� y This is to certify that the information provided is correct to the best o no dge d I u d I am responsible for all charges incurred from this application. DATE SIGNATURE CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY MUST CHECK ONE: ❑ 1. 1 OWN the property. 2. 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 on rized by the owner: I hereby give consent to the authorized representative of the Davie Co y I e enter upon above described property located in Davie County and owned by to conduct all testing procedures as necessary to determine s sit o ground absorption sewage treatment and disposal system. DATE SIGNATURE DCHD(1/93) 4 DAVIE COUNTY HEALTH DEPARTMENT " ' • Environmental Health Section Soil/Site Evaluation / J/ NAME DATE EVALUATED ' r ADDRESS PROPERTY SIZE PROPOSED FACIILTY � t�4!� LOCATION OF SITE . -/+ Ul Water Supply: On-Site Well 1l Community Public Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3 4 Landscape position Z_ Slope 9. 44 HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH t -� t 'u ✓ Texture group C 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: ,0Y EVALUATED BY: LONG-TERM ACCEPTANCE RATE: �i 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 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 ■■�■��■�■..�■■.�■■■�.■..�■�■■.. ■■..■.■■■■.■.■/■M../■■■...■MicJ■■ ■■■■...iiM■■■■M■■■■■■.■■■N■ ■■■■�1■■■■■M■■MMM...■■■..■....■/.....■. ■■...■uE■■■.N■.■M■■.M■...■i■■■■�.a■,r��.■■■N■ME■. ■■MNEME■ ■■.■■.■■■■ ■..■■1.M■I.\■■■.■■.Mi■..■.■■■■I.�J/1Vir■■■U■■ ■.■MC■ ■■■■■■C■■■■■■ ■■ ■MNEME./..M■\'iti►.U./�■.M1.■■Il.S':'■.��.i■`�'.ii■.`.r.■\`�:■..■N..■..■■ CCCC�i CCCCCCCCCCCCCCCCCCiiiiiiC CCC�CCCCC�:CCCCC�CCCCC'iiiCCRON ■■■■...■.�..■...■/./../■.■.■■.■.■..■■■■...■.■/■■.■ NMM/EMM■..■/ ■ 'CCCCCCCCCCCCCCCCCCCCCCCCCCCCCCC.■CCCCCCCCCCCC.Ni■CCCCCCCCCCCCCCCCCC ■■■■..■■■■■■■■■.■■■■■■NM■MU■■.■...■M..■�9M■■.EM.■■/■ ..■■ ■■■M■M. ■��iiiiiiC.�.ICCCCCC■��ii�ICCCC.��iiiiCCC■■CCCCCC.�iICCCCCC�CCCCCC.�.ICCCCCC■��i ..........■E■■■■■■■..0■■■■■■i>■■.■■■■■... ■.■■■.■ ■.■M■■NCMEMN■■ . ■ ...................................... .. ...■.. . ...■..■.■.■■■. ....................................■. �..... 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Please Fill In The Following Information About The EXISTING Facility: 1/ Name System Installed Under: to*� 111�e_�•.�'�ype Of Facility: Date System Installed(Month/Date/Year): �4K Number Of Bedrooms: 3 ,Number Of People:_ Is The Facility Currently Vacant? Ye� If Yes;For How Long? Any Known Problems? Yes Yes,Explain: Please Fill In The Following Information About T EW Facility: Type Of Facility: Number Of Bedrooms: Number of People Requested By: Date Requested:_, � e�� (Sign For Environmental Health Office Use Only Approved Disapproved Comments: dq IF Environmental Health Specialist Date: *The signing of this form by the Environmental Health a T is 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 Check"Money,Order # Amount:$ Date: 3 Paid By: l� ��'U E'/� Received By: G Account#: gG`a/)f,'�. � Invoice#: �r��