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193 Tom Crotts LnDAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION *NOTE: Issued in Compliance With Article 11 of G.S. Chapter 130a Sanitary Sewage Systems Permit Number Name `� , , t ---Date 1..� _ 1 N2 8142 Location _ J Subdivision Name Lot No. Sec. or Block No. t•- Lot Size —= ` — House — Mobile Home -- Business -- Industry r, r No. Bedrooms rte— No. Baths No. in Family — Public Assembly Other Garbage Disposal YES ❑ NO ©� Specifications for System: Auto Dish Washer YES ❑ NO p' ; 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. `Contact a representative of the Davie .County Heaj{1t,Depa t 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 completio4n!7 ,ephone ajp 704-634-5985:7'/En Final Installation Diagram G Syste stalled�by /GL2\ 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. r 1 APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMI • Davie County Health Department Environmental Health Section P. O. Box 665 Mocksville, NC 27028 Application/Perm Mailing Address AUG - 2 1995 i lo 2. Name on Permit if Different than Above 3. Application for: ❑ General Evaluation Septic Tank Installation Permit 4. System to Serve: ❑ House Mobile Home ❑ Business ❑ Industry ❑ Other 5. If house, mobile home: Subdivision No. of People No. of Bedrooms No. of Bathrooms 1 Dwelling Dimensions 6. If business, industry, place of public assembly, other: Specify type No. of People Served No. of Commodes No. of Lavatories No. of Sinks No. of Urinals No. of Water Coolers No. of Showers Water Usage Figures - 7. Type of water supply: Publi ZrPrivate 8. Property Dimension /� '£S Sewage Disposal Contractor 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? If yes, what type? ❑ Place of Public Assembly ❑ Unknown Section Lot # ❑ Yes ❑ Basement/Plumbing ❑ Basement/No Plumbing "ashing Machine ❑ Dishwasher ❑ Garbage Disposal In ❑ Community `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: 661 -t,— V I L9J tic- i. 1 i • 44d, &-�" - i I 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. 2 — q_� — &��Z d, 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 the Davie ou►�Y Heal Department to enter upon above described property located in Davie County and owned by - '419 �, g, to conduct all testing procedures as necessary to determine s)iid site's suitability for a ground absorption sewage treatment and disposal system. syps�tem... 0 di J DATE SIGNATURE DCHD (1/93) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation G� NAME L lr� Vy, �� DATE EVALUATED t� ADDRESS PROPERTY SIZE _ �� G c_ _ PROPOSED FACIILTY �� LOCATION OF SITE L V A"g Water Supply: On -Site Well " Community Evaluation Byk'�4jLAuger Boring V Pit Public Cud V FACTORS 1 2c k4 Landscape position 5 5 S� s Slope % o- ° o -b" S,3oa HORIZON I DEPTH Texture group OZ. Lt• - Consistence V= _T_ F Z '-IV Structure 2 C_* Mineralogy , 1 1 ; 1 '• HORIZON II DEPTH �" y1` n" 3� �` Texture group Q Consistence F -M Y� Structure ki Y-. %""r— kMineralo Mineralogy 1: 1 :) �, 1 A HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON — — -- SAPROLITE CLASSIFICATION s LONG-TERM ACCEPTANCE RATE a SITE CLASSIFICATION: `T 'S" EVALUATED BY: ;9��\ LONG-TERM pACCEPTANCE RATE: �� OTHER(S) PRESENT: \y��a REMARKS: \� C�a�. `►\ -�c =��\ �J�R. ` 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-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 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 ■�/�■��/��■��■ ��fl ■��■��■��■��n��■��■■ ■/��\■��■■��■��■ ■��r��■�■�0�■��■ ■��■■■��■��■/�■��■�■��■��■��■��■�■■ ■��■��■��/�� ■��■��■/��■��■ ■��■��■��■��■��■��■��■ ■��E��■��\�■��■��■��■��■ ■��■��/�■��■�■��■��■�■ ■�■��/��\��■�� ■/■��■��\��■■ ��■ ■��■��■��■■��■��\�■��■■ ■�■��■��■�\��■�r��■��■ ■��■��■ ■��\��■ ■��■■��■��■�� ■�i�� ■ ■��■��/��■��■ ��■��■ ■��■�� ■■ ■��■��■��■��■�� ■��■��■��■��■��■��■�� ■��■��■�■��■■��■■ ■��■�� ■��\�■��■��■��■��i��■�■ ■��■��■�■��■��\��\■��/��■■�■ ■■��■�\■■��■��e��\��■ �■��■ ■��■■�\�■��■��\��■��\�� iiiiiiiiiiiiiiiiiiiiiiisiiiiiiiiii=iiiiiiiiiiiiiiii�iiiiii��i=� ....................................................C......... ..0 :::CC:C:CCC:C:::C:C::::�::::::�3::::CC:C:=::C::C::CC�:C�:=:C: ■��N��■��/�■��n�� ■��■��h��■��■ ��■ ■��■�■■N■■��■��■ N��■�� ....o■.....................................■.....■C■■■.■......■..■ ................................................. ................ .................................................C................ ................................ ................................ 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