214 Vineyard Ln (4) ,a.N "• w<:Vr•-rw.:r�r 'ktx,cl.- ..,. _ - "_ . —. „- .. - r
E C EALT DEPARTMENT
DAVI COUNTY H
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION �N
*NOTE:Issued in Compliance With Article 11 of G.S.Chapter 130a -'
Sanitary Sewage Systems
r Permit Number
Q � �/f Date N- - 1
Name I 6
Location ./Za
o.-,� �--
Subdivision Name Lot No. Sec. or Block No.
Lot Size 9 c.' House Mobile Home — Business _— Industry
No. Bedrooms
OX. Baths —.-2 No. in Family — Public Assembly Other
Garbage Disposal YES ❑ NO 2-- Specifications for System:
Auto Dish Washer YES ❑ NO 00"
Auto Wash Ma shine YES p'' NO ❑ y v
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.
L7-jj
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.,
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 _2th .unm
_. 7b
Certificate of Completion r` Date -
1
'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.
C / 1*
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
l Davie County Health Department U��
1 Environmental Health Section IG
P. O. Box 665 J U L 14 1994
p Mocksville, NC 27028
0tv ------
1. Application/Permit Requested By
4 ------
1. 7/ ,,A /
Mailing Address � -� �c�rA-. �N�t.��wl.G�e ` Ci Home Phone q9A 7;),
Business Phone
2. Name on Permit if Different than Above
3. Application for: ❑General Evaluation k Septic Tank Installation Permit
4. System to Serve: ❑ House Ll 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 CT'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: Vublic ❑ Private ❑ Community
8. Property Dimensions tea- 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: a �
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.
—/#_ !T rn
DATE �r SIGNATURE
CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY
MUST CHECK ONE: ki�—�. I 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(1/93)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
/ Soil/Site Evaluation
NAME �l17 i. .0 DATE EVALUATED
ADDRESS PROPERTY SIZE
PROPOSED FACIILTY LOCATION OF SITE
Water Supply: On-Site Well Community Public Z1____
Evaluation By: Auger Boring Pit Cut
FACTORS 1 2 3 4
Landscape position
Slope Z
HORIZON I DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTHG
Texture group
Consistence
Structure
Mineralogy
HORIZON III DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION _7777-1-
LONG-TERM
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
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
sw
r Davie County NealtFr Department
and Nome Nealtfi Ayency
210 HOSPITAL STREET I P.O. BOX 665
MOCKSVILLE.N.C. 27028
PHONE:(704)634.5985
July 26, 1994
Nathan Smith
214 Vineyard Lane
Mocksville, NC 27028
Re: 2 Site Evaluations
Milling Road/3 1/2 Acre Tract
Dear Mr. Smith:
As requested, a representative from this office visited the aforementioned
sites on July 22, 1994. Based upon the information provided on the application
for a site evaluation and after the evaluations were completed, two sites were
found to be provisionally suitable for the installation of an on—site sewage
disposal system on each site.
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
cc: Jesse Boyce
Zoning Officer