165 Vogler Rd -
OV/
Ilk
DAVIE COUNTY HEALTH DEPARTMENT
' IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION f
*NOTE:Issued in Compliance With Article 11 of G.S.Chapter 130a
Sanitary Sewage Systems �411.11il/1'< Permit Number
Name� 1��^i�irX?n °L��/� Date _1.�" NO �7 3 4 5
Location
Subdivision Name Lot No. Sec. or Block No.
Lot Size—�� House Mobile Home Business __ Industry
No. Bedrooms --.No. Baths — No. in Family — Public Assembly Other
Garbage Disposal YES ❑ NO Q'' Specifications for System:
Auto Dish Washer YES NO ❑ ' y �Q �
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.
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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:7047634-5985.
Final Installation Diat ram:m System Installed by
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Certificate of Completion Date 1 D - 94
'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 EVALUATIOWIMPROVEMENTS PERMIT
e (`� Davie County Health Department "17R, IrF D
P.
Environmental Health Section nID
(� P. O. Box 665 LDEC' U ��
oa y Mocksville, NC 27028
93
1. Application/Permit Requested By
Mailing Address '\t . Home Phone q 5�o d
-OLa (P SIL'. 0�7�0G Business Phone
2. Name on Permit if Different than Above
3. Application for: O General Evaluation ,4{Septic Tank Installation Permit
4. System to Serve: p House L24bile 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 Y m4ashing Machine
No. of Bathrooms a Q-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 rivate ❑ Community
8. Property Dimensions jo a Sewage Disposal Contractor
9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes C-t'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:
del-paSS ��aJ ,
Dne �.� le GePq. (-)N Uol lid.
the lolnd ;s on R J14 dry Uv�ger,
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.
ra io - Q �
DATE SIGNATURE
CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY
MUST CHECK ONE: ❑ 1. 1 OWN the property. Y 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 thq Pavie County Heal h De ment to enter upon above described
property located in Davie County and owned by
to conduct all testing procedures as necessary to determine said site' uitability for a ground absorption sewage treatment
and disposal system.
-)t-/6 -9 '3 'w10 n-
DATE SIGNATURE
DCHD(1/93)
DAVIE COUNTY HEALTH DEPARTMENT
` - Environmental Health Section
Soil/Site Evaluation
DATE EVALUATED
NAME ,%��!"/4`�/�J/�/v
ADDRESS PROPERTY SIZE
PROPOSED FACIILTY LOCATION OF SITE
Water Supply: On-Site Well Community Public
Evaluation By: Auger Boring Pit Cut
FACTORS 1 2 3 4
Landscape position
Sloe %
HORIZON I DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH '-
Texture groupC
Consistence i
Structure IL"
Mineralogy /./
HORIZON III DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION U
LONG-TERM ACCEPTANCE RATEI
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
Mineraloizy
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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