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222 Shuler Rd (2) c.-�.,-.'+v•:..c 'vii"3>wL7+- ; ...j.,Yo;.•'" -.r" ': �`ra T .- .- - ., - _ °_ . , - '-. DAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION *NOTE:Issued in Compliance With Article II of G.S.Chapter 130a alta F Sewage-Systems _ r _9 _ Cf S Permit Number Name Date <P ` N2 70.84 Loceltiorl, - Lo Li Subdivision Name Lot No. Sec. or Block No. Lot Size J House Mobile Home Business Speculation No. Bedrooms .No. Baths No. in Family Garbage Disposal YES ❑ NO Seif�cationsfor System; Auto Dish Washer YES NO Auto Wash Ma.hine YES ❑ NP �--� 3 r �� r` ,. � `�1�r� �""� 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. 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. or 1:00-1:30 P.M. on day of completion. Telephone Number 704-634-5985. Final Installation Diagram: System Installed by _ Certificate of Completion Date 161 '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. APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT Davie County Health Department Environmental Health Section P. O. Box 665 h;UR+ $ 3 Mocksville, NC 7028 - wr.n�rrrrwrrrrrw 1. Application/Permit Requ sted By Le-"Y— Mailing Address Home Phone ' Business Phone 2. Name on Permit if Different than Above 3. Application/Permit for: ❑ General Evaluation Septic Tank Installation 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 3 ❑ Basement/No Plumbing No. of Bedrooms_13 ff Washing Machine No. of Bathrooms ❑ Dishwasher Dwelling Dimensions `"1 n ll ❑ Garbage Disposal I 6. If business, industry, place of public assembly, other: Specify type No. of People Served No. of Sinks v No. of Commodes No. of Urinals_, j No.of Lavatories No. of Water Coolers ! No. of Showers WateZuri ge Figures 7. Type of water supply: ❑ Public ate ❑ Community 8. Property Dimensions f1` Sewage Disposal Contractor 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes 13'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: `" This is to certify that the information provided is correct to theb of my knowledge, and-Lund tad I am responsible for all charges incurred from this application. 17,175 , DATE MVSIGN�r CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY MUST CHECK ONE: � 1. 1 OWN the property. ❑ 2. 1 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 representative of the Davie County Health Department to enter upon above described property located in Davie County and owned by to conduct all testing procedures as necessary to determine said site's suitability for a ground absorption sewage treatment and disposal system. DATE SIGNATURE DCHD(12-90) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation C NAME \ DATE EVALUATED ADDRESS c5 A m`e PROPERTY SIZE lJ OvZA PROPOSED FACIILTY LOCATION OF SITE Water Supply: On-Site Well Community Public Evaluation Byl�AugerBoring Pit Cut FACTORS 1 2 3 4 Landscape position S S 5 S Sloe 7. -Isc X5-15 HORIZON I DEPTH /.2" ID �Z' ��- Texture group Consistence Structure C C Mineralogy1 1'• HORIZON II DEPTH u -361, 3 ' Texture group C_ Consistence - _�' =� - Structure k Vas D k Mineralogy 1 t I HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS S-3 �s SS fs RESTRICTIVE HORIZON -- — — SAPROLITE — - CLASSIFICATION 5 5 Q LONG-TERM ACCEPTANCE RATE y Lf �4 SITE CLASSIFICATION: Q' S ' EVALUATED BY: LONG-TERM ACCEPTANCE RATE: 1 OTHER(S) PRESENT: �• �� REMARKS: EGEND 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 ■■■.■...■.....■.■■■■■■■■■■■■■.■■.■■..■■.......■■■■■■■.■.■....■■■MEN ■■ ■.■■.............■■■■■■.■■■i■■■■■■■■.■..■■MIS■..■..■.■■■■■.....�■■■ ■■.■■■■■■■■■■■....■■.■.■■■■�-.w■■ ■.ren.■■■■r�.r�■,n:■■■...■.....■..■■ iiiiiiiiiiii��:-aiiiiiiiiii�w:��'��■■�'�■■■■■■■■■■■s■■■■■■■■■■ I i::s iiiiiiMEMEME mmoiiiiiiiii ■■■.....■■.■■i•_■..■.■■....■■■■...■raw■■■■■■■■...■.■■■■■■■■....■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■i.■■■.■■.■■.■iii■■.■■r�M..M..M■t■■■■.M■■■■■■ ■■■.■■■■■■■■■■■■■■■■.■■■��■■■■��■ ■■■ ■.■■/I■■.........■..■■■�■■■■ ■■■■■■■■■■■■■■■■■■■■■■■.■■■■■.4\sal[�l�l■M..■■■II■■.■■..■.■■■■.... 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