535 Todd Rd (2) � :'M1.... , kt � ,.- � .:'-;'nom-4k�-::,<.yt"i :' `.J,Ti+x:v-��1 3;_ ..:t itl.•`+.;�,.n:.,..2 a �..,`..�+.r. s,-^e - .-.�. z.: - st . _ < - r ,
tl?. I/ X U
- .... DAVIE COUNTY HEALTH DEPARTMENT
„ .,.IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTE:Issued in Compliance With Article 11 of G.S.Chapter 130a f
a itary ewage Sy_ temb PermitMu
ber
Name _ _ Date
Location
Subdivision Name Lot No. Sec. or Block No.
0% V
Lot Size — House__T— Mobile.Home Business __ Speculation
No. Bedrooms .No. Baths / No. in Family _
Garbage Disposal YES ❑ NO ❑ Specifications pr fSy�em:
Auto Dish Washer YES 4 NO ED
Auto Wash Ma^hine YES � O ❑` %
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.
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. or 1:00-1:30 P.M. on day of completion. Telephone Number 704-634-5985.
Final Installation Diagram: System Installed by
rn
J,,,�
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.
a _ APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT rf 5�-
1 , W Davie County Health Department
Environmental Health Section
P.O.-Box 665
Mocksville, NC 27028
1. Application/Permmo Beq ested By
Mailing Address
Home Phone ` Zq
Business Phone
2. Name on Permit if Different than Above
3. Application/Permit for: [E Ge)nqal EvaluationIr Septic Tank Installation
4. System to Serve: ❑ House 0-Mobile Home ❑ Place of Public Assembly
❑ Business ❑ Industry ❑ Other ❑ Unknown
5. If house, mobile home: Subdivision Section Lot #
❑ Basement/Plumbing
No. of People > ❑ Basement/No Plumbing
No. of Bedrooms 0-Washing Machine
No. of Bathrooms ❑ Dishwasher
Dwelling Dimensions ❑ 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 Water Usage Figures
7. Type of water supply: ❑ Public Q-1!5rivate ❑ Community
8. Property Dimensions of - 9 Sewage Disposal Contractor
9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes �"o
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: 6 -7LO �� 1IV "7 V L i � C6-iWeA, L0
z(_.PJ Q rJ G/ / /`-F
l e,+4
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.
7-
DATE SIGNATURE
CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY
MUST CHECK ONE: 1. 1 OWN the property. ❑ 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 Health Department to enter upon above described
property located in Davie County and owned by
to conduct all testing procedures as necessary to determine said site's suitability for a ground absorption sewage treatment
and disposal system:
DATE SIGNATURE
DCHD(12-90)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
NAMEDATE EVALUATED
ADDRESS PROPERTY SIZE
PROPOSED FACIILTY LOCATION OF SITE
Water Supply: On-Site Well � Community Public
Evaluation By: Auger Boring t1__*1 Pit Cut
FACTORS 1 2 3 4
Landscape position L L
Sloe %
HORIZON I DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH Alg r
Texture group
Consistence
Structure / is
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:
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-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
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
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Y
Daae County Nealir De artment
� altFren
and dome
l
e y cy
210 HOSPITAL STREET I P.O. BOX 665
MOCKSVILLE.N.C. 27028
PHONE:(704)634.5985
July 14, 1992
Helen B. Everhart
Rt. 2, Box 425-A
Advance, HC . 27006
Re: Site Evaluation
Todd Road
Dear. Ms. Everhart:
As requested, a representative from this office visited the aforementioned
site on July 13, 1992. The site was found provisionally suitable for the
installation of a ground absorption sewage system.
If you have any questions, please feel free to contact this office.
Sincerely,
Robert B. Hall, Jr., R.S.
Environmental Health Section
RH/wd
Enclosure