526 Sain Rd -
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1, DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTE:Issued in Compliance With Article II of G.S.Chapter 130a
Sanitary Sewage Systems JI Permit. Number
Narver r, �,�� ��/ = -/:,� rls ",c / Date s'— '' :� - N2 U 3 .
Locati noe
Subdivision Name Lot No. Sec. or.Block No.
Lot Size /!F Hous@- �+R-� Mobile Home —T Business - Speculation-,,
No. Bedrooms No..Baths No. in Family _
Garbage Disposal -YES ❑ NO ❑ Specifications for System:
Auto Dish Washer YES NO ❑ -
Auto Wash Ma,hine YESr❑ NO ❑
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.
l r,;
Improvements permit by
"Contact a representative of the Davie County Health Department for final in$ ecti n of this system between 8:30-
9:30 A.M. or 1:00-1:30 P.M. on dk of completion. Telephone Number 704[[634- 985.
Final Installation Diagram: System Installed byf�x �[ l�C� ;
r
` '
Certificate of Completion ,,r' 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 betaken as a guarantee that the system will function
satisfactorily for any given period of time.
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation �}
NAME DATE EVALUATED `rl
ADDRESS PROPERTY SIZE
PROPOSED FACIILTY rr LOCATION OF SITE
Water Supply: On-Site Well Community Public t�
Evaluation By: Auger Boring Pit Cut
FACTORS 1 2 3 4
Landscape positionSlope Z
HORIZON I DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH ( l'
Texture groupC
Consistence i
Structure ,tom ,J
Mineralogy Al
HORIZON III DEPTH
Texture grou2
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE L
SITE CLASSIFICATION: EVALUATED BY: � iE1 I&
LONG-TERM ACCEPTANCE RATE: T_�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
Mi neralosty
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 chrome 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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r � APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
f Davie County Health Department
Environmental Health section �ECE�VEp
P. 0. Box 665
Mockoville, NC 27028 FEB 1 8 }
o4-
1 . Application/Permit Requested By i! .-� ✓ /� t S CK���: cr�/v.�,,
Mailing Address yv ks /c
Home Phone LQ:-J) Business Phone
2. Name on Permit if Different than Above
3. Property Owner if Different than Above
4. Application/Permit For: 0 General Evaluation Tank Installation
5. System to Serve: 5 House Mobile Home 0 Business
0 Industry u Other 0 Unknown
6. If house, mobile home: Subdivision Sec. Lot#
No. of People Dwelling Dimensions 0 f -1• Z_7 r
No. of Bedrooms asement/Plumbing
No. of Bathrooms ^ Basement/No Plumbing
Washing Machine e--rlshwasher 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
S. Type of water supply: ublic 0 Private 0 Community
9. Property Dimensions / G C- e,
10. Sewage Disposal Contractor ��4- 'r a0 ^
11 . Do you anticipate additions/expansions of the facility this system is
intended to serve? 0 Yes �"' \
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_.
/22
Datef
Signature JJ
Directions to Property : 4 .�
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DCHD (10-89)