1452 Underpass Rd DAVIE COUNTY HEALTH DEPARTMENT = �Z
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. • IMPROVEMENTS PERMIT I AND CERTIFICATE- OF COMPLETION
1
*NOTE:Issued in Compliance With Article I I of G.S.Chapter 130a
Sanitary Sewage S stems Permit Number
��sk \ � - � q� N° 7453
Name_-1"- ` Date`'`��f'` Q ry d��\\`o •-' 1
Location N<` *
Subd-iv s on Nape 7 Sec. or Block No. ��SZ C�
A
Lot Size �• �~��° House ✓ Mobile Home — Business -- Industry_____`__
No. Bedrooms No. Baths — 3 — No. in Family 3; — Public Assembly Other
Garbage Disposal �,YES [0" NO py'
Specifications for System: '• .
Auto Dish Washer YES [y' NO p /6o v 3, s �, c>a,
Auto Wash Ma^hive YES IR O p 'n
Type Water Supply _ ..0
*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.
(� 471
Improvements permit by ?•.>� �.�i
*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
Ji f7
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hb ( 6
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 PERMIT rr
i' is
Davie-County-Health-Department----
Environmental Health Sectionsr `( �/
P. O. Box 665
Mocksville, NC 27028 FEB 2 8 1994
1. Application/Perrhit Requested By i
0
Mailing Address �
�� l�f / 7 � laa rceg-Home hone 22?/-//-577
Business Phone
;1 ..
2. Name on Permit if Different than Above "
3. Application for: General Evaluation 23 Septic Tank Installation Permit
4. System to Serve: ® House ❑ Mobile Home ❑ Place of Public Assembly
❑ Business ❑ Industry ❑ Other ❑ Unknown
5. If house, mobile home:Subdivision Section Lot#
'®. Basement/Plumbing
No.of People C ❑ Basement/No Plumbing
No. of Bedrooms 3 10 Washing Machine
No.of Bathrooms _3 E3 Dishwasher
Dwelling Dimensions Q 61 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: a Public ❑ Private ❑ Community
8. Property Dimensions 3. S C"� Sewage Disposal Contractor
9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes ❑ 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.
Directions to Property:
Ord h�`J 04'V )Q
This is to certify that the information provided is correct tot best of my knowledge, t nd I am responsible for all charges
incurred from this application.
DATE SIGNATURE
C NSENT OR SITE EVALUATION TO BE DONE ON ABOVE DE=SCRIBED PROPERTY
MUST CHECK ONE: ❑ 1. I WN 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 f the avie Coun y Heal partment to enter upon above described
property located in Davie County and owned by 11,
to conduct all testing procedures as necessary to determ' a said site' abilit r ground absorption sewage treatment'
and disposal system.
!�_�9-q�
DATE SIGNATURE
DCHD(1/93) j
w
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS P 0-'11r "LN-AR
�
Davie County Health Department
Environmental Health Section
P.O..Box 665 _ ' 1994
Mocksville, NC 27028
1. Application/Permit Requested By 14 - Ve N r o
Mailing Address., X �
0— 11 ll c�
2\10 --766- 14V
�
Home Phone -'11 0 --76 6_ 14 u� Business Pho
2. Name on Permit if Different than Above
3. Application/Permit for: ❑ General Evaluation �ySeptic Tank Installation
4. System to Serve: ® House ❑ Mobile Home ❑ Place of Public Assembly
❑ Business ❑ Industry El Other ❑ Unknown
5. If house, mobile home:Subdivision Secti . Lot#
P3`Basement/Plumbing
No. of People -3 ❑ Basement/No Plumbing
No. of Bedrooms 3 ashing Machine
No. of Bathrooms 3CC&Dishwasher
Dwelling Dimensions ® Garbage Disposal
6. If business, industry, place of public assembly, other: Specify type
No. of People Served NNo. fnks
No.of Commodes
No. of Lavatories ers
No. of Showers res
7. Type of water supply: ® Public ❑ Community
8. Property Dimensions 1 actor
9. Do you anticipate additions/expansion f the facility his sytem intended to s rve? ❑ Yes ® No
If yes, what type?
'NOTE: Improvements Permits�halle v for a period of 5 y rs rom date issued. Improvements Permits are subject to
revocation, if site plansinten a change. Effec' October 1, 1989.
Directions to Pro .,rty: k Te r¢555
(",j douxl/yy 51 �.
This is to certify that the information p vided is corre to the best of my knowledge, and I understand I am responsible for all charges
incurred from this application. Xi&Llk
DATE V
SIGNATURE
CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY
Fandd
ECK ONE: ❑ 1. I WN the property. 9 2. 1 DO NOT OWN the property.
ked Box#2,the rest of this form MUST be completed by the owner or a person authorized by the owner:
ve consent to the authorized representativ of the avis County Health/Department to enter upon above_described
cated in Davie County and owned by 9 r-in 00 r✓ 2 Awe/ n
all testing procedures as necessary to determine said site's suitability for a ground ab orption sewage treatment
al system.
DAT SIG URE
DCHD(12-90)
' DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
NAME N �' �� P `� Q �� \\`C DATE EVALUATED 6
S `�^i�`Z-' PROPERTY SIZE
ADDRESS
PROPOSED FACIILTY a1� LOCATION OF SITE VuQ-c+ra� �Ct
Water Supply: On-Site Well Community Public V
Evaluation ByCkL Auger Boring V Pit Cut
FACTORS 1 2 3 4
Landscape position -s S -S
Sloe 9.
HORIZON I DEPTH
Texture group t-
C L L
Consistence FZ Z
Structure C R
Mineralogy 1 i : ► N I �11)
HORIZON II DEPTH Jq Z ` '1J1' 0 V, a "
Texture group C C C
Consistence fZ FIE F L F
Structure
Mineralogy
HORIZON III DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS SS .55 s Is SS
RESTRICTIVE HORIZON
SAPROLITE _
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE , 3 ,
SITE CLASSIFICATION: V S EVALUATED BY: n 1
LANG-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-Finn 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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