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375 Zimmerman Rd �4VIE COUNTY HEALTH DEPARTMENT JV ' IMPROVEMENTS�Yggf* AND CERTIFICATE OF COMPLETION *NOTE:Issuecb&tWpliaK'a ith Article II of G.S.Chapter 130a Sanitary Sewage Systems Permit Number Name 1 Date (O 17 N2 7610 Location aay c,c �l�`�e n•", Subdivision Name Lot No. Sec. or Block No. Lot Size C!"- House Mobile Home — Business —_ Industry .No. Baths No"'in Family _ Public Assembly Other No. Bedrooms --.5L Garbage Disposal YES ❑ NO [j-/ w;' Specifications for System: Auto Dish Washer YES p� NO ,❑ a Auto Wjsh Ma;hine YES [ NO Type Water Supply _ *This permit Void if sewage systemes abed below is not installed within 5 years from date of issue. This Wrmit i�s 6gctyq?y'Qc tt YifJ e plans or the intended use change. s z " { �. Provements permit by ON,", — r E_^ *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 J �•��_„ �c , - 1Aovs�' A G.P►'�e� Fu � N ` -7� bb EuF N �,- ��. ' d b p , .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. z ' poi � APPL I FOR SITE EVALUATION/IMPROVEMENTS PERMI �a�� Davie County Health Department S ,rA Environmental Health Section MAY 3 1 1994 • � ,�°) P. O. Box 665 Mocksville, NC 27028 r ~.-. ----------- --- Ada,- 1. Application/Permit Requested B Mailing Address Home Phone //�`�7`v / 3 Business Phone /� M- XQ ul 2. Name on Permit if Different than Above 3. Application for: ❑General Evaluation U`Septic Tank Installation Permit 4. System to Serve: [ 4ouse ❑ Mobile Home ❑ Place of Public Assembly ❑ Business ❑ Industry ❑ Other ❑ Unknown 5. If house, mobile home: Subdivision Section Lot # (Basement/Plumbing /,No. of People J ❑ Basement/No Plumbing ` No. of Bedrooms 3 Dashing Machine No. of Bathrooms 0-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 / 0-e-r G. 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: 4o ' 0 So I �iC°�- �ll��n (��S� J tAbe J �1 S �u � n 01� I�.eOples C�^��,K ��Qd- Tu.rr rt b» ej,u,t,.-�M �00-a - �-� ,� ��e-F� vn `�Yam e o a r.. r e cid c4 p►� r� - �� o-F r o Q� b , �r1 n �j o S This is to certify that the information provided is correct to the b st of my knowledge, and I u`hderstand I am responsible for all charges incurred from thisa plication. DA E SIGNATURE CONSENT FOR SITE E ALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY MUST CHECK ONE: 1. 1 OWN the property. ® 2. I 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: r, 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 det rmine said site's suitability for a gro absorption sewage treatment and disposal system. DATE SIGNATURE DCHD-(193) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section \ 1 1 Soil/Site Evaluation NAME ►/ c�1 C� S DATE EVALUATED ADDRESS S P �� PROPERTY SIZE PROPOSED FACIILTY 4 U S LOCATION OF SITE Water Supply: On-Site Well ✓ Community Public Evaluation By-C'�,L' Auger Boring Pit Cut FACTORS 1 2 3 4 Landscape position S S Sloe % - lb-O 4S- �� 15 Iti HORIZON I DEPTH L' " Texture group c, cL- S&L Consistence Structure (r">Z C; Z_ C. Z Mineralogy ;I 1 '+1 11 I I I HORIZON II DEPTH Lrx1' Texture group C, Consistence :T Structure Mineralogy ) HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS SS SS S RESTRICTIVE HORIZON - -- SAPROLITE — �- — CLASSIFICATION ,r $ _S LONG-TERM ACCEPTANCE RATE LAi SITE CLASSIFICATION: �' S EVALUATED BY: 9 LONG-TERM ACCEPTANCE RATE: ' OTHER(S) PRESENT: REMARKS: L GEND 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 (:lay 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 ■■■■■■■■■■■■■■/■t■■■■■■i/■■■■■■■■■■■■■■■■■■■■■■■■■lit■■■■■ ■ni■rA■ ■■■■■■■■■■■■■.■t■■■■■ilii■■■■■■■■■■n■■■■■till■it■■■■■■■■■■it■till■ ■■■■l■■i■■■■■i//■/■Ili■■■t■/■■■■ ■■ti■\/■//■/ii//ii///■■■i/////// ■■■■■■t■iii/■■■■■■t■■■■■■■■■iitt�l■■■■■■■■t■/illi■■■■hili/■■■■/■ ■■■■■t■■■■■■■■/■■/■■■■ii■■■■■■/■■/t■t■//■lilt//■■/iii■■■■■■lit■■■■ ■■■■■til■■■■■ilii/■i■Illi■.■■■■■t■■tl■■■■■■■■■.■■i..ii■/iiiii■ii■■ ■■■■■■■■■i■■■t■■■■■■/■■1■■/■■/■i■■1■■■■■■■iil.iiiiii.l■iii...■lti■ ■■■i■■i■■illi■■■■■■■■iiiiiii■■■■■■■■■■.■ill/.■.■.■■..■■■■■...t■.■■ ■.■■■■■i■■■ilii■■■■■■■■/■i■■it■■t■■■titi.t■■■■■■■■■■■ii■lt■■■■■■■ ■■■■■■■/til■li■■■/■t■■t■■■■dill■■ti■■■ti■■iii■■■t■■■■■.■�■■■■■■■■ ■■■■Illi■ii■■■/■■■illi■■illi■■t■�i■■■■■■■■.■■■l.■.■.■■■il.i.■■■■■ ■■■■■ii■■■■t■■■/■■■■■■■/■■■■//■■ ■■■■■■■ill■.■ii■ilii■■.ii■■■■.■■ ■■.■■■.■.■.■■i■illi■■.ill■■■iiiii■■■■■■■.■t■.■■■■■■■ii.i■■til/t■t■ ■Ilii.■■■■■■■■■■■■■/■ii■Iii■■iiiii■li■■■i■■i.■■■i■■■.■■■■■.■■■■■■■ ■■■.■ii■.■■■.■■t■■■■iii■■lit.■■ti.iit■■■■.t■■■ .l■■■.■■ ■■■■■■■.■■ ■■■■■■■■.■■■.■■■■■■■t■■.l■■■..■■hilt■■t�t■■■�■■■.■■■■�■■■■■.■I■■ ■■iii.iiiiitii■■i�iit/iiiiiiiiiii■■ilii■ li■illi■■■■■ll■■■■■■1 on ■■■■■■■■.■.t■■t■■■■■■■Iii■iiiiiiil■■■■■■■.■.ii■■■■■.ill■■■ill■■■■■ ■■■■lilt■ii.i■■■■tiiiiiii■iii■■�l■..■.■■■■■■■■■■.■■■■■■■■■■t■.■■ ■■ilii■Ili■t■■ti■■■■/■Ili■l/■■■ ■t■■itiltiiiiiiiii■■iii■.■■t./■i ■■■■■■■■■■■■■■■■■■iii■■■■■■■■■■■■■.■t■■■■■■.i■■l■■■■.■■■ii.■■til■■ ■liil.li■t.tlitii■■■■i.i■lii■iii...■.ii■■i■■■■■■■■�■■■■■■■■■■l■■t■ ■ii■l■lit■■t.i■■i■■■■iii■i.it//iitliliiiii■iiiii.■ ■iii■/ii■till■ ■■■■■l■..■i■■■■■ill■■■li■l■■■ii■■■ ■.ii.■■■■■■■.i■■■■■■i■■■i.t■■t� ■■■■■■■■■■it■i■■■■■ii■iillliiii■iiiii■i■■.■i.■.ilii■ ■l.iii.it ■■■ iii ■■.l■l■■.■..■■■■■■i.tui■■i.■ti.■■.■i■■.■l■■■■ln■■■■�■■■.■■■.Illi ■iiiii.■■ii■illi■■illi■/l/i■■ttiitliili..■tilt.■Ilii■ ■ill■lit■i ■ ■.ii■i■i.liltill■/iiiii■ill■ii■/iiiliiiii■■iitii■■ Mii.iltiiii■�i ■i■i.■i■/iitilti■t■iii■■.■■i.■■i.■■■■i.■■■t■.ti■■■C■.■■■■■.■■■■■t■ ■■i■■.■ii■..i■.i.tii■iiiii■tiilli.■iiliii.ti■■i.t■...■i.■■.■■■.■t■ ■■.■■■■■■■■.■■■■■■.■t■■i■■■■■■■■i■■■■■.i■■.■■ii■■i.l■■■til■i.■ii.■ ■iti.ilitii.ii.lit■itiiti■/ii/■l illi■iiiiii■l■i.11iill.■i■■l■■.■ ■■t■■■■■■■■..■..■■■it■i■■iiiii■iiiiii.iiiii■n■.ilii■ii■ii■iii■■ tilt■i■■■■iii■.■■..■ii■lith.li.■■■■■■■.■■t■.��itt7i■.l■■�.■■.i■■ ■■ii.■■i.■■i■it■i..■■■■■i■■.■■ii■...ii■.■■/.■ti.ill�/■■■■■■ ..i■i/■ ■■■■■iiiii■ii..i.iiitii■■l■lit■ii■.■■1.■�■■.lt■■t■11■CI■i■■■■■■■■■t■ ■■■■■■■■■■■■.■■l■■■i■■i■■.l■■i.■i■.■■i.l .■■itl,N■I,t■'li■■ii■i...i■■ =i�iiiiiii■�iiiiiii■�3iiii��.is�iii:�iiiiii�i�iiiiiiii�u=iiiii■�=iiiiiiit�■I ■■t■l.i■i■■i■■i■i■■■iii■.■■l.■t■i!.■i��■■■■■■t\I■■IIII■■1■■.■■..■■i■■■ ■■■■■.■l■■i.■..i..■l.l■■t■■illi/�LLail.■�►!■■��\l■.�111i■1■■■■■■.li■ii■ ■lt■l.■.■■i■■.■.■■■.■■.■iso.000iGii�CO!■i.!%II7■�2/rl1■w 1111�\'I■l.i�■■■l■■■■ EMENNEEMENNEEMOSOMMERim ::: :::_:: GC M=::::::� ■till..■ll.■■il.i■■.■\■ii■■■■.■■■�■■■ n■■li■■i1�1'i■Ilfl1■■■.■ili�MEMO ■■■■i..l■■■■i■■t■■■.■►.::G�lti■■l■t■l■■. ■ ■ ■I I/II■■ isZ111■■■■■■■i ■■■■ ■■■■■i.■.■■.■■■■■■■Gi■■.■t■■■■■■■.■■■■ ■ ■(, l,� iMIlilul■ ■■■■■■ ■ ■■■.■■.it■■■■■■■■.I■.n�■ii�l■■■■.■i■■ ■■■■■■■(�� 111� l/J�milm■l■�■■■■■■M■ ■■■■■■■■■■■■■■■■■■ll■l1�! \l■/It■■t.■i■!:�■■■■■■!■�■■■I�\v%�;WOMEN NONE mom NON ■■■■■■■■■■■■■■■■■■\i�1: :�I■■■■■■�■\.��7■ ■■■ �a ■�■� msf flll■t N■■■■■■ MOM■i■■/■.■.■■■■.■■■i■.t■lti■tl��.■ lil■■ati�.�hl . 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