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789 Turrentine Church Rd �fj rJ DAVIE COUNTY HEALTH DEPARTMENT is : � . � IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION *NOTE:Issued in Compliance With Article 11 of G.S.Chapter 130a ' Sanitary Sewage Systems Permit Number Name, AL X i%T% Date ND 6182 Location1�/S� ��i"t�'Ci � ', % pfd'^✓ ,7i, :�::/', i �� /,>�;'�✓ /�6�,: l Subdivision Name Lot No. Sec. or Block No. Lot Size-- Z House Mobile Home ��+ Business Speculation No. Bedrooms No. Baths No. in Family __ Garbage Disposal YES ❑ NO Specifications for System: Auto Dish Washer YES ❑ NO Auto Wash Machine YES ❑ NO /Ddo0 Type Water Supply t�Le.& --- *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. 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 El Certificate of Completion �Q� 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. • ,It ��+ APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT Davie County Health Department Gid 0 Environmental Health Section �� •� P. 0. Box 665 ��GLCIaV 4° �,o �D� Mockoville, NC 27028 1 . Application/Permit Requested By &' V T_ 2 fU Gv Mailing Address /,'1` �D u 3bvD �,�sU Home Phone Business Phones 2. Name on Permit if Different than Above ,0 3. Property Owner if Different than Above , -�-� ( /�s &c AJ 4. Application/Permit For : Q General Evaluation VS/Tank Installation 5. System to Serve: House T�-gobile Home 0 Business LL Industry u Other 0 Unknown 6. If house, mobile home: Subdivision Sec. Lot-# No. of People Z2 Dwelling Dimensions No. of Bedrooms J Basement/Plumbing No. of Bathrooms / ^ Basement/No Plumbing Washing Machine J Dishwasher 0 Garbage Disposal 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 S. Type of water supply: C Public Private Q Community 9. Property Dimensions z fezele-�s 10. Sewage Disposal Contractor ��o'o I AuG/If� 11 . Do you anticipate additions/expansions of the facility this system is intended to serve? Q Yes VNo 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. g. Date Signa re Directions to Property : 4-� •L'�� a7c / �!f'�£l�i�//✓ �s�i-!j�> �rGy/��af .y ��o7�1i171 (Tied G' Oct DCHD (10-89) 7W _�•' DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation > NAME �r DATE EVALUATED /�/,tom�y`iv ADDRESS PROPERTY SIZE /VAG. PROPOSED FACIILTY L� �/��P LOCATION OF SITE 2E'wP4`ez Water Supply: On-Site Well Community Public Evaluation By: AugerBoring Pit Cut FACTORS 1 2 3 4 Landscape position L L Slope Z G HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH �1 Texture groupC Consistence �_. 4)L Structure Mineralogy HORIZON III DEPTH Texture grouR Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION S �S 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 ........................... ...................................... .................................................................. .................................................................. .................................................................. ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■....■■■..■■■■...■.■■■..■■■■■■....■■t■t■■..■■■.■■■■t■t..■■■■■.�.■■ .....■....................■.............................. ........ .................................................................. isC:::::M:C:::: :::::: C::C:CSMENNEN�,�MEMNON C:::::�lMEMMEMi� ■■.■■■■■.■ttt■■.■t■■■■■■■tit■■■.■■■■■..■.��■■..■■r'+a■.■t■.■■■t■■■■■ ■..■■.■...■.■..■.■■■t■...■.■■■■...■...■............■■...■■■..�■.■■ ■......■..■.■...■■....■■....■..■....■i�==:.l... ■■I■..■■.■ ...■.■ ■ ■...■ ■.■■■■.■� ■■■■■■u■■■■■■■■■■■■■■■■■.■■■■■■ ■■■■.■■■■.■■.■ ■■■■■■■■■■■■■■■■■ ■.■■■■■M■■■ .......■■■■.■..■...■..■■....■....■■■.■■..■■...■... ■■ ■ecce■■■■■■eeeeeeeeeeeeeeeeeeeeeeeeeeee■■■eeeee■ee■■.eeeeeee■eeee■ ■■■■■■■■■■■■e■■■eeeeeeeee■■eeeeeeeeeeeee■e■eee■■■■ee.eeeeeeeeeeee■ iiiiiiiiiiiiiiiiii�iiiiiiiiiiiiu■iiiii;�iiiiiiiiiiiiisiiiiiiiiiii r DAVIE COUNTY HEALTH DEPARTMENT ENVIRONMENTAL HEALTH SECTION SITE EVALUATION CONSENT FORM 1. Complete the form below and return to the Davie County Health Department. 2. Carefully follow the procedures as outlined in the enclosed "Information Bulletin." NOTE: THE ABOVE MUST BE COMPLETED BEFORE A SANITARIAN WILL BE ABLE TO BEGIN THE REQUESTED EVALUATION. DETACH HERE AND RETURN TO: Davie County Health Department, Environmental Health Section, R 0. Box 665, Mocksville, N.C. 27028 Davie County Health Department Environmental Health Section Site Evaluation Consent Form LOCATION OF PROPERTY: DATE RECEIVED (office use only) y no 1. I am the owner of the above described property. yes no 2. 1 am not the owner of the above described property, however, I certify that I have consent from owner to obtain a owner's name site evaluation by the Davie County Health Department for the purpose of determining the suitability for a ground absorption sewage treatment and disposal system. yes no 3. 1 hereby give consent to the authorized representative of the Davie County Health Department to enter upon the above described property and conduct all testing procedures as necessary to determine its suitability for a ground absorption sewage treatment and disposal system. DATt SIGNATURE 4. 1 hereby authorize the Davie County Health Department to release site evaluation results from the above described property to the following: - Owner only — Owners designated representative —Anyone requesting results _iLOnly those listed below /� /7 0 DATE SIGNATURE DCHD(11/84)