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143 Wood Ln Lot 10 �x0 = DAVIE COUNTY HEALTH DEPARTMENT j IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION I 'NOTE:Issued in Compliance With Article II of G.S.Chapter 130a Sanitary Sewage Systems Permit Number Date —`��5 ' Ji N2 8089 Location /. .r i_ _�~ �G°� Y'S ✓f�_/7/�'i"! ( J fc{; !'/ .fir_ /_ v Subdivision Name �� i r" Lot No. /4 Sec. or Block No. Lot Size �'" !_a''% — House —L/— Mobile Home ---_ Business — Industry No. Bedrooms -c9 _No. Baths -- No. in Family — Public Assembly Other Garbage Disposal YES 0 NO C2- Specifications for System: Auto Dish Washer YES NO 0 Auto Wash fv a^hine YES NO 0 Type Water Supply -- Zfl ---- --- X �,� *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. f 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 D � � �. 44— F N Vy i Sa i ag r G r�P 072 ,y EvKNOO ) Certificate of Completion Date 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. DAVIE COUNTY HEALTH DEPARTMENT- Environmental Health Section �� ✓ Soil/Site Evaluation NAME PoSO"7✓ DATE EVALUATED ADDRESS PROPERTY SIZE / PROPOSED FACIILTY LOCATION OF SITE Water Supply: On-Site Well _ Community Public__ Evaluation By: Auger Boring Pit Cut FACTORS 1 1 2 3 4 Landscape position L Sloe Z HORIZON I DEPTH Texture group G Consistence Structure MineralogX HORIZON II DEPTH Texture group 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: /'� EVALUATED BY: Ala LONG-TERM ACCEPTANCE RATE: 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 ;lay loam SIL-Silty loam CL-Clay loam SCL-Sandy clay loam SC-Sandy clay SIC-Silty clay C-Clay CONSISTENCE Moist VFR-V,---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 ■......■■■■■■.■■■■■■■■■■■■■.■■■.■■■■■■■■■■■■■■■■■ ■■MMEME■ ■■■■D■■ ■.■■.■■.■■■■■■..■..■■■.....................■....■ ■EMMEM■M■EMM■■■■ ...........................................�........ ..■■..■■■■■.■ ■■..■■■■.■■■............■,.�i...E■��.a.■■=■■■■■■■ ■■■■_■■■■_■■■■■■■■ MMMMMMIMMIMMMMMMMMNM ■■..■■■■.■.■,....■.......■■■■■■■■■■■■■■■■ ■■■ ■ ■ E■■ ■■■■■■ ■■ ■■■■■■■■■■■■■■■■■■■■.■..■■■■■■■■■■■■■■■■ MEN IN MEMO ONMEN ■■■■■■■■■■■■■■■■.■■■■■.■■■■■■■■■■■■■■■■■■■..■■■■■ ■■■■MME■■■■■E■■■ ■■■■■■■■■■■.■■■■■■■■■■■■,■■.■■n ■■■M■■■■■■E■■.■.■■■■■■■■■■■■■■■■ MEMMIRRE ONE MEN MEN MEMPMEME ■...■.■enMM..■■..,.■■■■■■..■■.■■■■■■.■.■■■■H■ ■ ■■■■ ■■E.■. ■■■■■■■■■.■■■■.■.■■■■■■■E■■OM■E■■■■e.■■■■ ■■■■■■ ■ ■■ ■■ ■■■■■■■ ME ONE ENE M 0 UMEMEMMI ��Hn��.■ ■ IN Elm MEMO ' �MI MINIMUM ■■■.■■..■■.■■■■..■MM■■■■■■■■■■■.■■■ ■■ HpIMM� ■■ 'M■■■■ME■Emom � UMMOM■■MMMMMMMMN■E■■M■MMMMHO■ E■■■■MM.■■ ME ME M 0 mmllmmmmmmmmm I ■ a ■E■ MEMO■■ ■■■■■■■E■■■■■.■■■■■■■■■■H■■E■E■■■.■■E MN ■i.i.i■ii■■i■.....,,..■..............■ ■MMM ■■■■■■■M EMMEMMEN M■M■. ■ EMi EM 'iii'' " O ■ ■MEMMM ■ MEMEMM■MMI� ■MMMMMM.eMM...■ME■MMHM■MM■■.EMM N H■MN�MME■ ............ ■N■NN■ ... ... 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Box 665 Mocksv'le, NC 27028 . 1. Application/Permit RequetedBy !-� Mailing Address e 9'?,? ` rZ// Business Phone99 1o2 /O'y 2. Name on Permit if Differe*t than Above Di ee, Q1,v� � �� 9, , 3. Application for: ❑General Evaluation R;eptic Tank Installation Permit 4. System to Serve: House ❑ Mobile Home ❑ Place of Public Assembly ❑ Business ❑ Indu try (J❑ Other ❑ Unknown 5. If house, mobile home:Subdivision P' �-� section Z Lot #t, S"T',! 4e-T' -'V^T¢�e' A re,P-9.7 PS PCA Basement/Plumbing No.of People i ❑Zahing aent/No Plumbing No. of Bedrooms '3 Machine No. of Bathroomsishwasher Dwelling Dimensions ❑ Garbage Disposal 6. If business, industry, place of public ssembly, 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 ❑ Community 8. Property Dimensions 1 x a on !��` ewage 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: L _ U / -71by5' w 10 This is to certify that the information provided is correct tot be t of my kf�a edge, and I understand I am responsible for all charges incurred fr m thi application. DATE SIGNATURE CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY MUST CHECK ONE: ❑ 1. 1 OWN theproperty. (A 2. 1 DO NOT OWN the property. If you checked Box #2, the rest of this form MU T be completed by the owner or a person authorized by the owner: I hereby give consent to the authorized representative of the,Davie County a Ith Department to enter upon above described property located in Davie County and owned by to conduct all testing procedures as necessary to deter aid s' bility for a ground absorption sewage treatment and disposal system. DATE SIGNAtLA3E DCHD'(IP3) "i