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149 Wood Ln Lot 9 t � dvv�I • ,! APPLICATIObt FOR SITE EVALUATION/IMPROVEMENTS PERMIT p avie Count Health Department V�� Environmental Health Section L d 6 7 8 q 7d P. O. Box 665 -00 '" �J" Mocksv'le, NC 27028 1. A e B Application/Permit Re nested PP 4 Y Mailing Address e 1 '7.), 9 Business Phone99Jo2 /O-0 �7'ef ,f9 2. Name on Permit if Differe*t than Above i 3. Application for: 0 General Evaluation eptic Tank Installation Permit 4. System to Serve: House ❑ Mobile Home ❑ Place of Public Assembly ❑ Business ❑ Indu try ❑ Other ❑ Unknown 5. If house, mobile home: Subdivision -- �LLI � section Lot #t,•_,"=_7 5"T!��e i✓/ti✓i- � A re- pC f} Basement/Plumbing No. of People t7 ��ashirng ent No Plumbing No. of Bedrooms Machine No. of Bathrooms washer Dwelling Dimensions ❑ Garbage Disposal 6. If business, industry, place of public Issembly, 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 ��D X .� a •�� `� 8. Property Dimensions 5`ewage Disposal Contractor � 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes A3 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: OF—�U / l-7 W This is to certify that the information provided is correct to t bet of my-kn edge, and I understand I am responsible for all charges incurred fr mthi application. ,77 DATE SIGNATURE CONSENT FOR Sitt 5VALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY MUST CHECK ONE: ❑ 1. 1 OWN the property. [A 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 a Ith Department to enter upon above described property located in Davie County and owned by 7Y� f! i -<.!5)J to conduct all testing procedures as necessary to deter aids j' bility for a ground absorption sewage treatment and disposal system. 7 DATE SIGNATLARE DCHD(193) 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 14N✓'1 �-�"` ' Permit Number , Name %_�„ , r,; .� ''—-`%D`ate` " / '� ��"� N2 8091 Location W " �✓ i� �/ �' GU/o°a:�/{ice, �� //lti�? /� �)f i� C�. �.l Subdivision Name sem, '; 't Lot No. � Sec. or Block No. Lot Size House —� Mobile Home ^—__ Business -- Industry No. Bedrooms —.No. Baths — — No. in Family — Public Assembly Other Garbage Disposal YES Q NO [�]'� Specifications for System: Auto Dish Washer YES NO Q Auto Wash Ma^hine YES NO Type Water Supply ,-- �� ----- --- _4 G= S .t`'/ � 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 PERMIT/LAYOUT BEFORE INSTALLING THIS SYSTEM. --------------- r 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 — -- �J Certificate of CompletionG __ 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. ti DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section �� soy✓ Soil/Site Evaluation NAME DATE EVALUATED ADDRESS PROPERTY SIZE PROPOSED FACIILTY � �l�lO LOCATION OF SITEO�' c!C��/ Water Supply: On-Site Well _ Community Public Evaluation By: Auger Boring Pit Cut FACTORS 1 1 2 3 4 Landscape position ,L L Sloe HORIZON I DEPTH Texture groupL Consistence Structure Mineralogy HORIZON II DEPTH '" 3 Texture groupG 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: -A ZZ LONG-TERM ACCEPTANCERA E: OTHE (S) PRESENT: REMARKS: _�c� P /Prf, t�So, ihJ �t 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 wateC 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(01-90) ■■■..■■■■.■■■■■■■.■■■■■■■.■■■■■.■■■■■■■■■■■■■■■.■�■■■■■■■■ ME■■■■■ ■■■■■■■■■M■■■■■■■M■■■.■M■■■E■■.M ■■MMMMMMMEM■■MMMMM■MMMMMMMM■MMMM■ ■■■e■■■■■■■■.■■■■■■■■.■■■■.E.■E■■E■■■■■■■■SM ■■.■■■.■■■..EEE■■E■M■ ■■■■■■■■■■■■■■e■■e■■.■■.■■■■■■■■■■.■■■■■.■■EM■■■E■■M■EM■■■■■■M■■■■ .......................■.■.C........■■..■■EE■ME�ONE Eloomommo ME MOM■MEMM■MME■ i =ii ■■■'iiiii.MIiNN ■■■■■■■■■■■■■■■■■■■■.■■■■■■■■■■■■■■■■■■■�■EMNo ■■■■■■■■■■.■■■■.■■.■.■■■■■■■■■■f" ■��.■■■■.■.■■■...■■■■.■MENEM ■■■■ ■■■■■■■■■■■■■.■.■■■■■■■■.■■..■■Iii■■■.■■■■■■.■■■��■■..■NHE.E■■.■. ■■EE.■ENOMM■■■M■.■.O■...■.M■..E ■.■■M..N ■�■MNNMM■■MMM■S■ OEM ...............................................■ .■E■■■MM■M■E■■■■■.■ .■■. 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