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134 Quail Hollow Rd Lot 8, Sec 1 l/ 0 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 _ Permit Number Name Q9 � _f o I<1' / � �`'�v. ':` `7Date �1'-" i" -9 N o 1 73 1 J Location e6z I%', ,1 /`✓. ;,, :��,/ — — s �,l Subdivision Name rtr J� / f�� Lot No. Sec. or Block No. Lot Size Z2L House Mobile Home _'Business Industry 1 No. Bedrooms - --.No. Baths ,. 1--V ' No. in Family __ Public Assembiy `Other Garbage Disposal YES ©" NO 2 Specifications"for System: Auto Dish Washer YES NO ❑ Auto Wash Ma^hine YES 0' NO ❑ -1y 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. F Improvements permit by *Contact a representative of the Davie County Healt qt artment r 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 completi Tel ho6e Number:704-634-5985. Final Installation Diagram: System Installed by _ o� l� 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. � d -F6 7 APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PIRMIT Davie County Health Department Environmental Health Section MAR 1 5 1993 P. O. Box 665 I , Mocksville, NC 27028 1. Application/Permit Requested By Mailing Addressejc s &X 7 /920 C/---s � _ /1`.C. p70.a S Home Phone 4«f�- '7J 7� Business Phone 99k - 7a 7 9 2. Name on Permit if Different than Above 3. Application/Permit for: General Evaluation ❑ Septic Tank Installation 4. System to Serve: 90Ouse ❑ Mobile Home ❑ Place of Public Assembly ❑ Business ❑ IndustryJ-16 ff ❑ Other C3 Unknown 5. If house, mobile home:Subdivision 9IAlL fidG.L6Section Lot # _ ❑ Basement/Plumbing No. of People ❑ Basement/No Plumbing No. of Bedrooms [ Washing Machine No. of Bathrooms 2 7-0 eDishwasher Dwelling Dimensions 91'Garbage Disposal 6. If business, industry, place of public assembly, other: Specify type No. of People Served No. of Sinks No. of Commodes at o r'— 3 No. of Urinals No. of Lavatories No. of Water Coolers No. of Showers Water Usage Figures 7. Type of water supply: C7 Kblic ❑ Private ❑ Community 8. Property Dimensions / A CSP— t-0 M Sewage Disposal Contractor 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes DINO 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: This is to certify that the information provided is correct to the best3LrQy knowledge, and I understand I am responsible for all charges incurred from this application. DATE SIGNATURE CONSENT FOR SITE EVALUATION TQ BE DONE QNN ABOVE DESCRIBED PROPERTY Fandd ECK ONE: ❑ 1. I OWN the property. ❑ 2. I DO NOT OWN the property. ked Box #2, the rest of this form MUST be completed by the owner or a person authorized by the owner: ve consent to the authorized representative of the Davie County Health Department to enter upon above described cated in Davie County and owned by all testing procedures as necessary to determine said site's suitability for a ground absorption sewage treatment al system, MATE SIGNATURE r _ DAVIE COUNTY HEALTH DEPARTMENT ~ Environmental Health Section L bt \ Soil/Site Evaluation NAME �� N C �Z S DATE EVALUATED 3 — J o 13 - 93 ADDRESS o\L 3 6 PROPERTY SIZE PROPOSED FACIILTY o LOCATION OF SITE Q Caw' Water Supply: On-Site Well Community Public Evaluation By:C E L Auger Boring Pit ✓ Cut FACTORS 1 1 2 3 4 Landscape position S Slope % C - b' 0 , 5'O HORIZON I DEPTH Texture groupC C L Consistence '�- Structure e , Mineralogy HORIZON II DEPTH Texture groupt Consistence Structure 8 Mineralogy HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS S SS RESTRICTIVE HORIZON -- SAPROLITE CLASSIFICATION S, LONG-TERM ACCEPTANCE RATE 0A I SITE CLASSIFICATION: _R_ EVALUATED BY: .s, , � - LONG-TERM ACCEPTANCE RATE: OTHER(S) PRESENT: REMARKS: �� '�� ',N. �_ 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 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) ur AR - Long-term acceptance rate - gal/day/ft2 DCHD(01-901 ■■ ■■..■..■■..■■■■■..■■■.■■..■■■■■■..■.......■■■■■....■....■.....■ ........................... ............................. 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