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720 Underpass Rd �} 0 \ =' DAVIE COUNTY HEALTH DEPARTMENT 4 IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION *NOTE:Issued in Compliance With Art'clp.l pfkG S- -hapter 130a - Sa i a �Se a e,Syst s '"�`' '� c�f � r�, , Permi u er . d rte ' /,.� l Name Date No ��/ / VfiC'!_ ! sJ./�� 111�Ii / �,✓ (�/i�ll�'f..%'.YS_..% ` Location Aewr r----- — — 4Z. '"' r r r7 Subdivision Name Lot No. Sec. or Block No. Lot Size f House Mobile Home — Business Speculation No. Bedrooms No. Baths No. in Family — Garbage Disposal YES ❑ NO ❑ Spe ifications for System: Auto Dish Washer YES NO ❑ � ( �., •tr Auto Wash Ma^hine YES On,❑ / W�t/1 llG 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 u e 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 Inst Ifed'6y— 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. @ IE 0W� ,. APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PE I Davie County Health Department AUG 2 3 1,003 -� Environmental Health Section P. O. Box 665 Mocksville, NC 27028 1. Application/Permit Requested By /� / Mailing Address /�l3 ��X �� s/vA.vz�` ,/l� G• 7y0� Home Phone 2&6 7-- y/& Business Phone 99p- 2. Name on Permit if Different than Above 3. Application/Permit for: ❑ General Evaluation 92-teptic Tank Installation 4. System to Serve: eHouse ❑ Mobile Home ❑ Place of Public Assembly ❑ Business ❑ Industry ❑ Other ❑ Unknown 5. If house, mobile home: Subdivision Section Lot# ❑ Basement/Plumbing No. of People 3 ❑ Basement/No Plumbing No. of Bedrooms 93,'Washing Machine No. of Bathrooms Z LT'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 93/Private ❑ Community 8. Property Dimensions Sewage Disposal Contractor 9. Do you anticipate additions/expansion of the facility this sytem 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. Directions to Property: 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 CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY MUST CHECK ONE: ❑ 1. 1 OWN the property. fiZ�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 theDave 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. a zs9-Z DATE SIGNATURE DCHD(12-90) DAVIE COUNTY HEALTH DEPARTMENT `w Environmental Health Section / Soil/Site Evaluation NAME DATE EVALUATED ADDRESS PROPERTY SIZE 3r,4qe PROPOSED FACULTY LOCATION OF SITE Water Supply: On-Site Well � Community Public' �� Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3 4 Landscape position Sloe Z HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH t" _V(o Texture group Consistence Structure Mineralogy i J,' i 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 r SITE CLASSIFICATION: EVALUATED BY: a�/ 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-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 .................................................................. ■■■.■.■.■■.■■.■.■..■.■r�■■■..■■■.■■_■■■■■.■■■■■■■■■■■ ■■■■■■■■■■■.■ ■■.■■■■/i■■■/..■.■■.e■ie■■...■■/�e./■./■■e�.e.■■i/./■./ee//■■�/■■ ■■.../..■■..i■..■e.■■/■■■e■■■//■■■/■■■■/..■■.■■..■.■e=■.■■■■■■■■ ■ :�:: ■■.■■■■■■■■■■■■■■■■.■■■■.■■.■■■■�■■e■.■■ee■■■ ■e■■...■■■■.■■...■ ■.■■■.■.■■■■■■..■..■.■■.■.■e■■e■■■■■...■■■■■■�■■■■■.■■■■■■■.■■■■ iiiiiiiiiiiiiiiiiiiiiiiiiiiiiiii�iiiiiii�iiiiie■riiii■iii■iiiii�■iii MEMEMMOHiiiiii.■ .........................rr............■.i. ...... .......C■■■e■■■. ■■.......■..■.........■.■r1■■.■...■.■.■■rl.�■■■■■. ■�■■■e.i..■..■.e MC ■. :■I:I::�_::::::� ................................�.....�... ■. ■ ■■ ■...■. ■.■■■..■.■.....■■■■..■■■■►�•_e�■■��.■� ■■■■■■►� ■■■.■■■■■■.M■■■■ MORMAMO......■..........■................. ........�::'. ■.■■■■eC■e■■■.MEMMENI iiiiiisiiiiiiiii■iiu�iiiiiiiiiiiiiiii■■iiiiiii ME= i iio■iiiNEE ii■ ■■e....../...■/.i■..e./.........� ■■■■e■■..■■■■■■■■■■.■■■■■■■■■■■■ MONO MEMMEMEM ■■■.■ ■■.■ ■■.■■e■■■■.■e■.■■ ■■■■■u■■■■■■■.■■■■.■■■■■■■■■■.■■■■■ ■■0 ■ ■. ■■■.■■.N■.■■■ ■.■■.■. ::�:::_:::::::C:::::�_::':�::. 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