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141 Wood Ln Lots 11 & 12 t/Xa DAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION ,3 0 *NOTE:Issued in Compliance With Article II of G.S.Chapter 130a Sanitary Sewage Systems Permit Number Name �'�r . �_ !`. ,\'}, \'�> c.� t~'--- Date �� _ N2 8 Q 1 Location V,, -f�rnso� �ar`k- Subdivision Name Lot N69 3�� Sec. or Block No. Lot Size -, ``—x �� — House _V Mobile Home ---_ Business -- Industry No. Bedrooms No. Baths -- — No. in Family-L4 — Public Assembly Other Garbage Disposal YES p NO p'/ Specifications for System:r, Auto Dish Washer YES p-' NO p Auto Wash Ma-hine YES [L' NO E] ? `� Type Water Supply _ C" k. �.rc.� '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 ATTENTION: YOUR SEPTIC SYSTEM CONTRACTOR MUST SEE THIS PERMITILAYOUT BEFORE INSTALLING THIS SYSTEM. r " l Improvements permit b P Y --=— — '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. FiniJtl`stPat nt iagram: System Installed by c C) N vs � 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. ` APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PER ' Davie County Health Department D Environmental Health Section P. O. Box 665 I'M 8 Mocksville, NC 27028 ENVIRONMENTAL VI /'i� HEALTH1. Application/Permit Requested By. �6 r%1N0/ COUNTY Mailing Address Y7�� ,C��'Slrr" l� /V Home Phone /,2/O) L✓n/ Gr� /U� 2 710.3 Business Phone 2. Name on Permit if Different than Above 3. Application for: ❑General Evaluation U)'9e—ptic Tank Installation Permit 4. System to Serve: M- ouse ❑ Mobile Home ❑ Place of Public Assembly ❑ Business ❑ Industry ❑ Other ❑ Unknown 5. If house, mobile home: Subdivision Section Lot # C/ U 8asement/Plumbing No. of People / 2 ❑ Basement/No Plumbing No. of Bedrooms J "ashing Machine No. of Bathrooms I'?— M,bishwasher Dwelling Dimensions LIS X 32- 15-3 , rre2l"' ❑ 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: D-Public ❑ Private ❑ Community 8. Property Dimensions�_T�y�U S. r'r74 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: FROM 1�r1I��Te y� ,�o fet,1�.� Far'rhJ 74,.!/,yeti r¢a�v�.vret %Nrw lell- ON pad �o No f f o PR J� �X Kowr d r Re a/.,/d /.?/. rf/d0 d/ IV r'r C 5 r4 ac�rD y� C& le/t w.(«e 14r e. T,' 7•<d n��,�6e��o 4,e 464 Wq.sX,,, 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. Z IfXS- DATE SIGNATURE CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY Fnd ECK ONE: OWN the property. T ❑ 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 representativ f t e Dat County He�Ith gee ent to enter upon above described cated in Davie County and owned by �� .I�o�,IJ Yk� _ 01' � �1 ,1 all testing procedures as necessary to-determine said site's- s itability for a ground absorption sewage treatment al system. ATE SIG ATU i" DCHD'(1 J93) • . _ . . .. _ ,� = I_ I Q S 30 *w - �r ' - - ` b l• OV W DRIVE LIU _ 22,447_ SQ. FM- S I. 04' w t - �` EAll cif v"� SO' St•o�'v�r _ Is, I3 A o - s cc 7-7 . FT, y 0 .; IAl tr 42. Slo . � NOTE: OWNEfZSHIP OF 3 bY.._. — - ,�• ••� N ICCTAINLfl !Y STIM�oK P!►RX_ - I ' 3 :RAY- C. HENDRIX —. . , -•, .. - 1 2 _ 16,940 sQ:FT.'r rl _ 121054 SQ.FT.� 4 its,Ar `roc��` - -- •_. - St•Oi.'W .23Gi '. _ :. r-_.... .. ;;- __.. .. _ ROI. CORNERS SHOWN -THUS O - ��. MARKED—WiTK IRON S XKVS , �. ,. ter 1 DAVIE COUNTY HEALTH DEPARTMENT • Environmental Health Section Soil/Site Evaluation NAME \"� � C��,�� U DATE EVALUATED (.5' ADDRESS Q PROPERTY SIZE PROPOSED FACIILTY IAO v s� LOCATION OF SITE Water Supply: On-Site Well _ Community Public Evaluation Bye,4i. Auger Boring Pit Cut FACTORS 1 1 2 3 4 Landscape position -151-8 s .S -s Sloe % C"IGv -1S' B-16a HORIZON I DEPTH 4_." Texture group Consistence s Structure MineralogX fVA ( 1 HORIZON II DEPTH 4n w t` Texture group Consistence -r_ Structure Mineralogy JI ` 1 I ' HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS SS RESTRICTIVE HORIZON SAPROLITE -- — — CLASSIFICATION P.s, PA LONG-TERM ACCEPTANCE 'RATE SITE CLASSIFICATION: St EVALUATED BY: LONG-TERM ACCEPTANCE RATE: OTHER(S) PRESENT: O 9 REMARKS: -L93a� d' 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 :lay loam, SIL-Silty loam CL-Clay loam SCL-Sandy clay loam SC-Sandy clay SIC-Silty clay C-Clay CONSISTENCE Moist VFR-V12-y 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 ,3C--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 ■■■■■■.■■.■.■.■■■■.■■■■■■■■■■■.■■■.■■■■e.■■■■■.■.�■.■..■.■ ONE .......................................... ........ ............. ■.■■■■■■■■■■■■■....■■■■■■.■ ■■■■■■■■■■■■■■■■■■■ ■.■■ ■■■■ ■■■■■■.■ ■■■■■■..■..■■.■■.■■■■■■.■.■■■■■..■.■■■■■ MEN C■HCC.■■..H'C.■ ■.■.■■...■■■■■■.■.■■■.■■■.■■■■■...■■■■..■..■.■■■ EN . ■■■■■■s■■■■■■■■■ ■■...■■■■■■■■.■■■.■.■■■.■.■■■■■■.■ ■ ■■■■■■ ■■■H■■■■■■■ ■ ■E■■■ CCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCC'■'■CCCCCCCCCC�CCC'CCC """"""""""""""""�""""'■C■s""i■i■CCCCCCCCC'i■CCC ........N■■e■N■■■■.■■■.■.■■■■■■■■■■■■■■■■■■u■■N o=:'C■CCCCCs.0 CCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCC.. .CCCCCC'CCCCCCCC ................■............... ■CCC.■■■■■n■■n■■n■■n■■ne■C■■�■■i■■n■.n■■n■■u■■■■n■■�■■i■■n■.n■.n■■n■■n■■C■.�■■■■"■■■■■'■■■��■"�■■■■■."■■■■■"■■■■ .'■C■■n'■■�C ■Cn■■N.'■■■C■C■ Eom R.■.■.•.■.■.■ CsON ■ ■■ ■ MEN OMEN CCCCC:Cownno�CwnsoonwCCCCNOMMMEMONCCCFCC ■■.■■■■■■■■■■■■■■■■■H■■■■.H■■■■■■■■■.■.■■■N■■■u.C■..■e1!��ae■■■■.■■■.■.. ►,�� ■Cw ' . .■■■■ ■ ■ ■■N ■■■■■■ ■■ ■■■■■■ ■ ■■■■■■.■ ■■■■■■■■■■■■eN■■■■ a■r.:�=��.....�u. , ■ I ON ■H■■ ■■ ■■■■■■■■■■■un■■■■w■■ri■■■■■ u �iMEMO i a■ ■■■■■w■ ■■■■■■■ ■■Nn■■■N■■■1 99,1N■■pI ON ■\z■l sssCssss�CCCCu■u■■i�i iiCCCCC NO ■ii■.■."C MIAPENN C ■■■■■■■■■s■■■■■■■NN■, ■N■■■N. 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