171 Wood Ln Lot 6 DAVIE COUNTY HEALTH DEPARTMENT
\ IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
{
*NOTE:Issued in Compliance With Article II of G•.�,Chapter 130a
Sanitary Sewage Systems A"2 vc, I, �-�' ' Permit Number
Name J ��: rr .�!'%' l Date ` � / ` -��' C N2 8093
Location
Subdivision Namei'•,, . �✓ I- Lot No. Sec. or Block No.
Lot Size , 1' — House — Mobile Home ---_ Business -- Industry
No. Bedrooms r�—.No. Baths — No. in Family _ Public Assembly Other `
Garbage Disposal YES ❑ NO CX. Specifications for System:
Auto Dish Washer YES NO ❑ �
Auto Wash Ma^hine YES 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
ATTENTION: YOUR SEPTIC SYSTEM CONTRACTOR MUST SEE THIS PERMIT/LAYOUT BEFORE INSTALLING THIS
SYSTEM.
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
N o Q .5 � y
d _
Certificate of Comopletion — —_ 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 / r
Soil/Site Evaluation /
NAME �//� �cSg DATE EVALUATED
ADDRESS PROPERTY SIZE �J
PROPOSED FACIILTY LOCATION OF SITEd�DCi'
Water Supply: On-Site Well _ Community Public
Evaluation By: Auger Boring Pit Cut
FACTORS 1 1 2 3 4
Landscape position L_ L
Sloe Z
HORIZON I DEPTH
Texture group �C
Consistence
Structure
MineralogX
HORIZON II DEPTH y -'-
Texture groupC
Consistence r
Structure 1e
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: KY�//
LONG-TERM ACCEPTANCE RATE: 1211 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-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
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APPLICATIqbt FOR SITE EVALUATION/IMPROVEMENTS PERMIT
avie County Health Department ��r 6 .7
Environmental Health Section
P. O. Box 665
Mocksv'le, NC 27028 `
1. Application/Permit Requested By
Mailing Address e929 -` A 2
j( Business Phone9y"2 /O-yL'0"Gf'/�r
2. Name on Permit if Differeot than Above
3. Application for: a 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 4 Se ion Z Lot #t,,_
$TF"-r-ev P(-A7 Basement/Plumbing
No.of People ��7�ashllrng
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
8. Property Dimensions `fid x vZ 490 A�•�ewage Disposal Contractor
9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes Er 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:
cls U l�p,j&1OA)A
q w
This is to certify that the information provided is correct to t be t of my-kna dge, and I understand I am responsible for all charges
incurredfr m thi apvplication.
DATE SIGNATURE
CONSENT FOR SItE EVALUATIOTO i3E 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 thee Davie ountya 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. ' -
4-a 1-9
DATE SIGNA E
;� DCHD*(1193)