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109 Quail Hollow Rd Lot 1, Sec 1-art:.. - .. ... • - XO DAVIE COUNTY -HEALTH DEPARTMENT IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION *NOTE: Issued in Compliance With Article II of G.S. Chapter 130a Sanitary Sewage Systems /;J, //` Permit Number Names l /�1 iIi fir,.., �� iS %lr%� 9 Date -S"-12 S- AYy N2 7568 Location Subdivision Name �� I Z/ Zhl l Lot No. __________ Sec. or Block No. Lot Size '�iJC_ House �Mobile Home _T Business Industry No. Bedrooms --2—. No. Baths ! '} No. in Family _ Public Assembly Other Garbage Disposal YES ❑ NO p' Specifications for System: Auto Dish Washer YES NO F-1 Auto Wash Ma:hine YES NO p 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. Fin Improvements permit by//17 �� *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: 704634-5985. Certificate of Completion _L 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. 0 APPLICATION FOR SITE EVALUATION/IMPROVEMENT S PERMIT _ ..-.._.. Davie County Health Department ✓ Environmental Health Section r;`i1R 1 5 19 p�-)7w� P. O. Box 665 Mocksville, NC 27028 1. Application/Permit Requested By -ZNC_ . Mailing Address �i 8 �v X �� 7 �%ZOCI�s ✓!t �.rc _ /IZ. C. Home Phone Business Phone 7--1 7 f� 2. Name on Permit if Different than Above 3. Application/Permit for: General Evaluation ❑ Septic Tank Installation 4. System to Serve: House ❑ Mobile Home ❑ Place of Public Assembly ❑ Business ❑ Industry ❑ Other El Unknown 1�1 5. If house, mobile home: Subdivision ctA/L A164-&6CJ Section Lot # �. . No. of People No. of Bedrooms No. of Bathrooms 2 7-0 v� ;��, Dwelling Dimensions 6. If business, industry, place of public assembly, other: Specify type No. of People Served No. of Commodes a. a -3 No. of Sinks % No. of Urinals No. of Lavatories 3 No. of Water Coolers _ No. of Showers a— Water Usage Figures _ 7. Type of water supply: public ❑ Private 8. Property Dimensions / A CA -,Ir-- Sewage Disposal Contractor ❑ Basement/Plumbing ❑ Basement/No Plumbing o'Washing Machine El/Dishwasher Garbage Disposal 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes EVNo If yes, what type? ❑ Community *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 incurred from this application. / DATE knowledge, and I understand I am responsible for all charges J2 -y- SIGNATURE CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY MUST CHECK ONE: ❑ 1. 1 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 (12-90) FACTORS I 2 3 4 Landscape position ' DAVIE COUNTY HEALTH DEPARTMENT Slope % -is U -%0 Environmental Health Section Texture groupL Soil/Site Evaluation C L (� NAME _ LJ �-�` N �� S(�Co N DATE EVALUATED - - 9 3 ADDRESS PA_ 3 L-1\\\ PROPERTY SIZE �L () �n PROPOSED FACIILTY o S LOCATION OF SITE Water Supply: On -Site Well Community Public Evaluation By:e�-L" Auger Boring Pit V, Cut 3 Mineralogy l '. ► j'. 1 FACTORS I 2 3 4 Landscape position S Slope % -is U -%0 HORIZON I DEPTH Texture groupL C L Consistence -L Structure C C R Mineralogy HORIZON II DEPTH Texture groupC Consistence S - Structure AB`F 3 Mineralogy l '. ► j'. 1 HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS 5 S Ss RESTRICTIVE HORIZON — — SAPROLITE — -- CLASSIFICATION S LONG-TERM ACCEPTANCE RATE 4, SITE CLASSIFICATION: _ \?•5 LONG-TERM ACCEPTANCE RATE: ' H REMARKS: DCHD(01-901 EVALUATED BY: lft.'A' OTHER(S) PRESENT: 2-'A 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 TPY*11- 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 -Finn 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 ■■■■■■■■■//■■■//■/■M/■E/■■■IEEE■■■/■//■■■■■■■■■■■■■■■■■■■■■■■■ ■■■ ■■/■/■/■■■■■■■■■//■■■■/ee■■eee/N ■/■■■■//■■■■■■■■■■//■■■■/■■■■/■■ .................................................................. ....................................................... .......... ■■■■/■ ■/■■■■ ■■■/■/ ■■NNe■ ' ■■■//■ /e■EEN ■■■/■■ ■■Nee■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■ ....................■■■■■■■■■■■E■■■■■■■■■C■■■■■.... ........■.■■■. ■■■■■■■■■■■■■■■■■eeeN■NNENEee/Ee ■■■/ NEEM■■■■■■ ■■ ■ ■■ ■■■■■■■ .....................................■///NNN■■■■C■//MNE■■■■■■CN■NE�r ::::CCC:::::::CCC:::::::::::CCCCCCCCCCCCCCCCCCCMEMONOMMON MENEM IN ........................................................ ........ ................................................�.......�■■■MEM■MC� V■eeeeeeeeeeeeeee■NEENNN■■NNNNNN ■E/NN■■M■■■■ ■M■■■eeeeee■/■■■E■/ CCCCCCC■■■CCCCCCCCCC■CCCCCCCCCCCCCCCCCCCCCCC■�=CCCCCCCCCCCCMM CCCCC ::CCC ;.�!_CCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCC:CC:CCCCCCCC■.C.CCCCC ■■■■■■.are■■■■■Nee■■■■■NN■ENE/Ea■■■■■►.Ji/■NCNEEMMEN■M■MCMEMEN ■■N ■■eME�wvE\lE■■■■/ee■■■■Nee■■■eNNN ■/■■/■�G■'7��NE■■■■■■■■■///NN■■//■ ■■■eee\►�/%ecceNEE■■eeeeee■eee■e■■■■NNNrI/■�,•t/ERIN■NNN//NN■■NE■■M■■■■ ■■/■■MEI■■■■■■/■■■■■■M■■■■■■■■■M■■NE■■11��/�1E/I■M■■■■■MM■■ /NNE//■■ ■■///■ENE■■■■E//N■N//NeeeeNNNNNe■■/eH►_��■■/■eee■■eeEC■■■■■■■■ ■■■■/■■/■/■■/■N■■■■■/■//■N■NEN■/■■■M■■■///■/NN■■■■■■■■■M■N■■■■■■■ ■■■■Nee■■■//eN■■■■■/�■■■■■ENE■M■ N■/■■/E/■■■■//N/■■■/■NNNNNEN/■N/ ■//■■■■■■E■E■■EEEN■■■■■■■■NNee■■�■■■■eeeeeNee■eHeeee■■■eee■■■eee ■■■/////■■■■■■E■■/■/■■■■■■■■■■MEM■■■■■■■■■■■■■■■■■■■■■■■■N■■■■■■■ ■■■■/eee■■■ecce■■eee■■■■■■■■■■■■■■■�■■■■e■■■■■■■■■■■■■■■■■■■■■■e■■ ■■■eeeeeeeeee■■eeeeeeeeeeee�e■■ecce■■■■/■■■EE■■■■■■■■■■■■■//M■■MN■ ■■■■■■EE/■■NEE■■■■■NiN/■M■■■EE/�■■■■EE■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■NN■■■■ENEN■■E■/■/■■■■■N■ ■■eee■Nee■■■eeNeeeeee■eeeeeeNee■ ■eeeeee■■■■■eee■■■■■M■eee■■■■eeH■■■■eeie■■eeeeeeeee■■EeeeeNE■■eel.!