194 Sain Rd l =" DAVIE COUNTY HEALTH DEPARTMENT
b' IMPROVEMENTS PERMIT AND .CERTIFICATE OF COMPLETION
*DOTE:Issued in Compliance With Article II of G.S.Chapter 130a
-Sanitary Sewage Systems Permit Number
Name N 6749
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Location ��-' ✓ (YY`) /f J� �1.<�_ —
Subdivision Name - -- Lot No. Sec. or Block No.
Lot Size 11-11el' House Mobile Home_ti` Business Speculation
No. Bedrooms 'r-7 —.No. Baths — _ No in Family -
Garbage Disposal YES NO ❑ Specifications for System:
Auto Dish Washer. YES NO ❑ %'
Auto Wash Ma thine YES p NO ❑ h"G i
Type Water Supply
*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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1
Improvements permit by --�-'1�12 Z-/-
*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.
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Final Installation Diagram: System Installed
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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.
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4
APPLICATION FOR SITE EVALUATIONAMPROVEMENTS PrUIT
Davie County Health Department R EEC,F QV E
Environmental Health Section 7
P. O. Box 665 1992
Mocksville, NC 27028
1. Application/Permit Requested By
Mailing Address 1� - )'1 o&(J rR c,�� �� '�e7 mon__!5'
Home Phone ��"/ /[�� "�% Z5 �� Business Phone — a ��� ��'f�
2. Name on Permit if Different than Above
3. Application/Permit for: ❑ General Evaluation Septic Tank Installation
4. System to Serve: ❑ House ta Mobile Home ❑ Place of Public Assembly
❑ Business ❑ Industry ❑ Other ❑ Unknown
5. If house, mobile home: Subdivision Section Lot#
❑ Basement/Plumbing
No. of People ❑ B ment/No Plumbing
No. of Bedrooms Ing Machine
No. of Bathrooms Dish er
Dwelling Dimensions oQ qpp rox. ;-Garbage Disposal
6. If business, industry, place of public a sembly, other: Specify type /" Z14
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: (P Public ❑ PrivateCommunity
8. Property Dimensions QUA Sewage Disposal Contractor
9. Do you anticipate additions/expansion of the facility 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 subject to
revocation, if site plans or the intended use change. Effective October 1, 1989.
Directions to Property: Q C — t�1 (/� 'SL /n t,
'
Paste ��,r�,� / L{se
/ Urn rl �� �� Rin J u s�
ova r� h
C)
re- r-o, r �d uh f /es C��-'1Q s are
_ � are, house
r� Veda ��� J ;jle, n ear-
�� � �` off,
hoc sib' Posse hL0 . ahs OL 1
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 SIGNATURE
CONSENT FOR SITE EVA ATION TO BE DONE ON ABOVE DESCRIBED PROPERTY
Fandd
ECK ONE: 1. 1 OWN the property. ❑ 2. 1 DO NOT OWN the property.
ked Box #2,the rest of this form MUST be completed by the owner or a person authorized by the owner:
ve consent to the authorized representa tinf,thy,Davigd//Coun y Health Department to enter upon above described
cated in Davie County and owned by (,ff Gir l�'e- Kf i f�—
all testing procedures as necessary to determine said site's suitability for a ground absorption sewage treatment
al system.
DATE SIGNATURE
DCHD(12-90)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
• Soil/Site Evaluation `
NAME G` � �`f DATE EVALUATED
ADDRESS PROPERTY SIZE � G
PROPOSED FACIILTY ze'zk gs a LOCATION OF SITE
Water Supply: On-Site Well Community Public
Evaluation By: Auger Boring �� Pit Cut
FACTORS 1 2 3 4
Landscape position 4 `—
Sloe %. a'-
HORIZON I DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH
Texture group
Consistence
Structure Ste/ S-�Z
Mineralogy / /.'i i.-/
HORIZON III DEPTH
Texture grouR
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION S S
LONG-TERM ACCEPTANCE RATE / 46
SITE CLASSIFICATION: v EVALUATED BY:
LDNG-TERM ACCEPTANCE RATE: OTHER(S) PRESENT:
REMARKS:
LEGEND
Landscape Position
R-Ridge S-Shoulder L-Linear slope FS-Footslope 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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