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bAVIE .COUNTY HEALTH DEPARTMENT )
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTE:Issued in Compliance With Article II of G.S.Chapter 130a
Sanitary Sewage Sy tems , Permit Number
Namey� � V A't" w ; .. Date ( �3 N_ 7365
Location !' `J_ J -� tyy �aN cQ \v \� 1 0 0
Subdivision Name Q� �2��� ��` Lot No. Sec. or Block No.
Lot Size 'House: ✓ Mobile Home —� Business -- Industry
3 � � ::.
No. Bedrooms No. Baths _�—�No. in Family "?' _ Public Assembly Other
tiz
Garbage Dispos"al, 'YES p?; NO [y Specifications for.System:
Auto Dish Washer " ` - YDS [ NO ❑
Auto Wash Ma thine YES cy NO Q.
Type Water Supply _ `C����� `i
*This permit Void if sewage system described below is not installed within 5 years fromdate of issue.
This permit is subject to revocation,i,f site pia,rls or the intended use,change.
Yf
R
J
0
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 —
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.
T 'G -. �+fes i y i i 'Y ♦ .'A t a.y,ry l L._• _ y t i ..
DAVIE COUNTY HEALTH DEPARTMENT 60♦a o
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTE Issued in Compliance With Article II of G.S.Chapter 130a
Sanitary Sewage Sy tems _ Permit Number
_' m V A�v C?w ____._ Date � � � � U ' �� 0
Name — N- 7365
Locations io l V 'i:,t"' c Q
Subdivision Name S�C t`�"�" �~-\ ~1�� Lot No. Sec. or Block No.
Lot Sizeru rHousey Mobil Home �� Business _— Industry
No. Bedrooms 3 ;No-. ''Baths— r 5:",No,,intt'Family ~� r Public Assembly Other
Garbage Disposal, YE9.1'6 NO t ; 'L ;•5lyecifications for System:
Auto Dish Washer YES jG NO ❑ .t t.i t =� L-r-a� C�
Auto Wash Ma^hive YES:[n NO ❑ � ' 0 NX
� '
Type Water Supply
'This permit Void if sewagesystemdescribed below is not installed within 5 years fromdate of issue.
This permit is subject to revocation if site plans or th•e intended use change. to
`
�� T• i
-------------
-T
�J
1.
�t
� r
•, l
Imp'rovemer
�t ,
s p r it by
i
*Contact a representative of the Davie County HealthliDepartment for final inspecii-on 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-f; -5985.
System Installed b
Final Installation Diagram: -�-°�••--�°-•�-"�"' s•' ? ; . � y —
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 PERMITS -`
*� Davie County Health Department
Environmental Health Section NQU ,r
P. O. Box 665
Mocksville, NC 27028
1. Application/Permit Requested By. 3 0� , e o S�,7 �—
Mailing Address o:7S '5-c A P,T f Home Phone
cL VA-14 c C- /yI � -2— Business Phone 9 9.h'- Y-3 3
2. Name on Permit if Different than Above �J ) AY 4 e
3. Application for: ($"General Evaluation ❑Septic Tank Installation Permit
4. System to Serve: iE'House ❑ Mobile Home ❑ Place of Public Assembly
❑ Business ❑ Industry ❑ Other ❑ Unknown
5. If house, mobile home: Subdivision S�� �1 �o �� Section Lot #
❑ Basement/Plumbing
No. of People ❑ Basement/No Plumbing
No. of Bedrooms 3 'Washing Machine
No. of Bathrooms Q-Dishwasher
Dwelling Dimensions s3 X ❑ 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 1 Water Usage Figures
7. Type of water supply: K1 Public ❑ Private ❑ Community
8. Property Dimensions �10-T-Cm Sewage Disposal Contractor Z
9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes ❑ No 7,
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: nn _
�tN bs`U U� v 7La N ,V't
r
-4 � ��� �� � ���� � (' s
� y
This is to certify that the information provided is correct to the a of my knowledge, and I understand I am responsible for all charges
incurred from this application.
�- -73
DATE byJNATURE
CONSENT FOR SITE EVALUATION!Q BED NE ON ABOVE DESCRIBED PROPERTY
Fand
ECK ONE: ❑ 1. 1 OWN the property. 2. 1 DO NOT OWN the property.
ked Box#2,the rest of this form MUS be completed by the owner or a person authorized by the owner:
ve consent to the authorized representative of the Davie County Health Department to enter upon above described
cated in Davie County and owned by
all testing procedures as necessary to determine id site's suitability for a ground absorption sewage treatment
al system.
DATE SIGNATURE
DCHD(1/93)
DAVIE COUNTY HEALTH DEPARTMENT
• y'` Environmental Health Section
Soil/Site Evaluation
NAME Yom`' "� +' DATE EVALUATED 1 - y
ADDRESS s rn Q PROPERTY SIZE 7 O_E_5� n
PROPOSED FACIILTY av s Q LOCATION OF SITE S�\� 2� R�
Water Supply: On-Site Well Community Public 1/
Evaluation By:C_',1Z,, , Auger Boring Pit Cut
FACTORS 1 2 3 4
Landscape position �5 cS S'
Sloe % O C)` �_-) O` 0 -
HORIZON I DEPTH r % " 1 157 g '
Texture group L C L_
Consistence
Structure C l
MineralogX
HORIZON II DEPTH 3 d"
Texture group
Consistence
Structure
Mineralogy
HORIZON III DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS S S
RESTRICTIVE HORIZON
SAPROLITE — — —
CLASSIFICATION P.S
LONG-TERM ACCEPTANCE RATE ,3
SITE CLASSIFICATION: ;�>§ S EVALUATED BY:
LONG-TERM ACCEPTANCE RATE: OTHER(S) PRESENT:
REMARKS: �"(y�.o.� 1 `� \_Xr�w. �LEGERD
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
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(01-901
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IVAN D. ADAMS
DB. 137 PG. 267
alp
solid
S 87.43'19" E elp
975.06 0 N 88.13'28" W
428.63
6 O BILLY F. WEST
` g DB. 58 PG. 172
`\ AREA a2.241 ACRES
o ao
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ARNOLD D. SMITH
4P j 55 W p`o m DB. 78 PG. 105
\M J. HARTLEY O s �929c0� y o
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nip op R� -4 1 i-3 s
Tabor 'Y
41 0110
$ z JOANN C. COX I
P �y g m DB. 117 PG. 770 li
axle 0 363.14 O 375.88 O
a�9ry au.by� S 89.43'36" W rabar 5 89.45'39" W Irofid
n.
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N sJ.2jB39 ^'y O
nip 38.924 TpT4 `fo' �i p 0 S 89.19'26" E
Ip < -, p r- 142.96 ZT
'93
.9 Snlp PQ� O ur v W
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ulp S 86.48' ro J
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547.13 m
el TniP 530.23 TO O11e o swe
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bAy
,0 509,14 c
nip 1
AREA n 5.331 ACRES
vim, ryp ry�
`o AREA a 5.503 ACRES
r.73 TOTAL B'56'29"W "IP o
580.04 27.69 822.34 TOTAL;dp s 88.56.29" W b LEE JUDITH WARD
nip 2769 794.65 "Ip wg DB. 99 PG. 54
3 o m5.001 ACRES v m
o ro AREA 0 5.894 ACRES
to
nip 1405.49 o.le
` -- 5 88.56'29" W 1405.49 TOTAL
`r V
1
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t
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IVAN D. ADAMS
i; DB. 137 PG. 267 s
7 : 1
w iZ t
1 r
alp (olid 1 a 1 t
S 87•
75.06 - N 88.13'28 W
' 428.63
OBILLY F. WEST'
6 $
DB.._50 PG.'172
m AREA=9.241 ACRES n
ro '�' 0� alp O
O ..IPA
1 p
X01, :'ARNOLD D. SMITH 1
DB 78 PG 105: b
9�0 L 418.1 I
tM' J HARTLEY 9a 1
103 PG.';840 w lk 0 06. alp In N 88.3S 01 E
G• nl 8 ee•10'86"W' ni t
01 y 418.28
Nro PGQ PI t-OS 89.46'01'E ��IJ
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alp g
rabN
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JOANN C. COX
P� �e ■at. I mll DB. 117 PG, 7701
U 363.14 0 r -375.88 aolid0
p�94Pa1yb •` �.--5 89.43'36" W nbar 5`89.45'39" W Iron
b +
r0r- C4
nIP J�JS•42 TpTgC S 89 19.26.,E
h r 142.86 -�
'ice.' '9459 nip Y;`�•,+p PQ• O v.
J lO►i
atp S 86.48'IS" E
547J3 �
d /-'nip 530.23 TO as o sweet
p -L N 8 TAL � la O awasl eum
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0 �.
nip 1
AREA=5.331 ACRES
' vwy np,' 1y0, _
h AREA=5.503 ACRES
lu 607.73 TOTAL /
nip.. Y 88.56'29"W alp
580.04 27.69 822.34 TOTAL v ~
i H nip S 88.56,29" W p v. LEE JUDITH': WARD
i O
nip 27.69 794.65 "tp a DB.', 99 PG. 54
o m O
AREA■5.001 ACRES v .
A
o n AREA=5.994 ACRES _
1 .
h
nip ' 1405.49
mla
.r-- S 88'56'29" W 1405.49 TOTAL