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141 Tennyson Ln (2) DAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENTS PERMIT AND .CERTIFICATE OF COMPLETION �° * 'NOTE Issued in Compliance With Article I I of G.S.Chapter 130a Sanitary Sewage Systems Permit Number �- Name /S�f��:r� ,�T///:'�Y�1,� ,9i, J�.// Date N2 N2 •"�:-�' Location % C'"- � a�% 1 f ��i'>l% A..� r ' Cf �� _ .• � , �� Subdivision Name Lot No. Sec. or Block No. Lot Size ? House 1�.--'"' Mobile Home _� Business Speculation No. Bedrooms r No. Baths �� O No. in Family - `�, Garbage Disposal YES ❑ NO p1 Specifications for System: uc Auto Dish Washer. YES p NO ❑ / �, v Auto Wash Ma^hine YES (p NO ❑ /�� "�`�l'' d `�-'' � 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. i 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. or 1:00-1:30 P.M. on day of completion. Telephone Number 704-634-5985. Final Installation Diagram: System Installed by— �WIL , � 1- �D Certificate.of Completion Date *The signing of this certi icate shall indicate that the essystem described above has been installed in compliance with the standards set forth in,the a6gve 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 PERMIT rr` t �' �►► Davie County Health Department Environmental Health Section P. 0. Box 665 Mocksville, NC 27028 1 . Application/Permit Requested By A -- -- Mailing Address oPr/-%� G ��Ile Home Phone . 5 Business Phone 2. Name on Permit if Different than Above 3. Property Owner if Different than Above 4. Application/Permit For: neral Evaluation S/Tank Installation 5. System to Serve: House Mobile Home 0 Business L Industry u Other 0 Unknown 6. If house, mobile home: Subdivision Sec. Lot# No. of People _ Dwelling Dimensions No. of Bedrooms Basement/Plumbing No. of Bathrooms %%? Basement/No Plumbing 0 Washing Machine C] Dishwasher 0 Garbage Disposai 7. If business, industry, 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 B. Type of water supply: G Public 91-frivate Q Community 9. Property Dimensions 10. Sewage Disposal Contractor 11 . Do you anticipate additions/expansions of the facility this system is intended to serve? Yes 0 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. 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. Date Signature Directions to Property : DCHD (10-89) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation NAME �!/�J� DATE EVALUATED ADDRESS PROPERTY SIZE �A(i PROPOSED FACIILTY t ll--,�� LOCATION OF SITEr�/ ',� Water Supply: On-Site Well Community Public Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3 4 Landscape position AP Slope % HORIZON I DEPTH Texture group Consistence Structure MineralogX HORIZON II DEPTH 2/ y/ Texture group Consistence Structure /YI Mineralogy �.: HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION i LONG-TERM ACCEPTANCE RATE , SITE CLASSIFICATION: G EVALUATED BY: 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 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-Film 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 SC-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 ■■■■ecce■■■..■■■■■■■■■■■■■■■■O.■■■■e■■.■■■■■.■.......■.....tt■��■ ■■eee■■■■■■eeeeee■■.■■■.eeeee■■■ ■■■■■■■■■■■■e■■■e■■■■■■■■■■■■■■■ ■■■■■■■■■■■■ecce.eee.■■■■■■■■■■■■.■■■■■■■■■...........t..t.■.■.■.■ ■.t..■..■■t...■..■.■t..■■■.■e.■■.■■n■rpt■irt►i.tt.■■■■■■■■tt..tttt.■ ■.....■■\��..■....■.■■■■■■.■IA..■ ■■.0.■......■..■..�■��■■■i■■■■MEN■ .....................eee.■■e■■■.■.■.............................C. 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