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172 Vogler Rd DAVIE COUNTY HEALTH DEPARTMENT 11��' ow '`. IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION 'NOTE:Issued in Compliance With Article II of G.S.Chapter 130a ry Sewage Systems Permit Number NametSanita cj - � >_`;�: s Date _ NB 1905 Location — c� �r., 1 _ t:: t�o ,`, ;ata: .. _ — + r \ y l4 11 V, da i R" Subdivision Name Lot No. Sec. or Block No Lot Size 1 ' '' House —� Mobile Home --_— Business -- Industry No. Bedrooms -_.No. Baths nt— No. in Family _ Public Assembly Other Garbage Disposal YES C3 NO p` Specifications for System; E) Auto Dish Washer _ YES ❑ NO f J p r , f r Auto Wash Ma^hine YES ❑' NO [] Type Water Supply �1 -- --- '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 ATTENTION: YOUR SEPTIC SYSTEM CONTRACTOR MUST SEE THIS PERMIT/LAYOUT BEFORE INSTALLING THIS SYSTEM. 1� 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 ��+�T2�-- Co- �i O 8' .......... ;L N 1 J Certificate of Completion �_� �=? — Date Jb '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. ; r APPLICATION FOR SITE EVALUATION/IMPR( V Davie County Health Departme t '' " ` 5"M® 05� _ 44 Environmental Health Section ' P. O. Box 665 F E B 2 21995 Mocksville, NC 27028 --- '---=------ . 99��oa54 1. Application/Permit Requested B'y1 /a 1n�1 Mailing Address 17a. Or) 9 l 9-LA-, Home Phol!nee 8,dadpi` Q--Z 7006 Business Pho e y7 77 2. Name on Permit if Different than Above 3. Application for: ❑General Evaluation ligeptic Tank Installation Permit 4. System to Serve: 0"H-ouse ❑ Mobile Home ❑ Place of Public Assembly ❑ Business ❑ Industry ❑ Other ❑ Unknown 5. If house, mobile home: Subdivision Section Lot # O Basement/Plumbing, No. of People ,S ❑ Basement/No Plumbing No. of Bedrooms "ashing Machine No. of Bathrooms o� 1� L�shwasher Dwelling Dimensions !X J ❑ 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 9?15r-15r ❑ Community 8. Property Dimensions I 1 71 a CJIJ� Sewage Disposal Contractor 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes la'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: C- T yo F�s-� /5,0q VW 4-0 �'o Y O U �J CDMA i w +c> Aq c 0,q rJ C e- A loo u 4- M; 1, $ ruA v e�-f- ,�'f� �.` 1 Ao Xd A K Ae 6 s . u/Gr jv y 6 Q e d�-+ �e ,'� 4-0 Y.0 ce o•4 a ;-o y--A e c0 a OA C/ W o� s444 0-0¢ g, � /Z�4 v�� . fpusv 9e� milt . e OX, s '�✓ a RoB�/ be p -f-tb b 7-6 68-4e0 f✓oqr�kNS . 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. 1 A ep y— , SIGNATURE CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY U� MUST CHECK ONE: 1. 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(1193) i • DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section (� Soil/Site Evaluation c� q NAME ''N V'y's DATE EVALUATED J `� ADDRESS � PROPERTY SIZE PROPOSED FACIILTY X�oySQ' LOCATION OF SITE Water Supply: On-Site Well _ Community Public Evaluation Byjtti-` Auger Boring Pit Cut FACTORS 1 2 3 4 Landscape position -s Sloe Z o Eo HORIZON I DEPTH Texture group �— Consistence 71 Structure G 6` Mineralogy HORIZON II DEPTH h 34. " Texture group Consistence F l'=2 Structure Mineralogy HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure MineralogX SOIL WETNESS s ss s.T RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION S .• S S LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: 5, EVALUATED BY: LONG-TERM ACCEPTANCE RA TE• •'I OTHER(S) PRESENT.: �Q REMARKS: LEGEND Landscape Position R-Ridge S-Shoulder L-Linear slope FS-Footslope 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 ;lay loam, SIL-Silty loam CL-Clay loam SCL-Sandy clay loam SC-Sandy clay SIC-Silty clay C-Clay CONSISTENCE Moist VFR-V+:.-y 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 ■......■...riiia!�7■/■■.■.■.M.■.■■■..■.■■■■■.■■!..■■■■■■■..■■■■■■■ ■.■.■■...■.fir■rit�W■■■/.■■.■■.■.■■�NE.■.■.■■■■■.■.■ ■!.!■■■■■!!!■■ ■■■■■....■■.■..■■..■■.■/■■■.■.■■ ■■■■.■...■■.. ■..■■■■■■■■.■■MEMO ■■..■.!■■!.■....■�i■■■.■■M.■ ■!.■■.■■■.■I■■O■■■M�E■■EIw■1■�■■■■■■■! ■■■■ME!■■.l��ai��J■■..■■■.. ■.M...MM.■. ■MEMOMM NONE SOME MEMEMEME ERROR ma ■■1■■■■■■ MINE MMEMMEMMEM MINN ■DOE■M..■O■O.O.■OE■..■E■.■/■lOMEO!!■O!1lO11l111M1�1E111111110lO11■ ■.l.■.■OM■.■M!.■■E■!■■.■!■■■O�l�■!■.O■M.MM.E■MEMOMMOI■1111■■O!1■ ■■■MOO■!MOlO■!■O1EM■..E■■■■.I�■li7\IE.E■■EM■M.O■M■ ■ ■EE.■■!■■■■■E■ IMilEili■MiM=iiiiom M E ■■ .......■..■..................... .■...■■■E�■E■E . ■■■■.■..■■ ■■s ................................ ........ .. .................. ■■.!!■■■11M!■M.MM!■.E.EE■aM■■EEE■.■a..■■.■■.E■ ■■■.■_■■■■■■■■.■.1� ....................M.N.■■..■..■■■■■!M!!O!■■MM1 ONO M■MMO■MM!■� iiiii■1liiii�MMi