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140 Quail Hollow Rd Lot 7, Sec 1 w DAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENTS PERMIT AND CERTIFICATE OF- COMPLETION •NOTE:Issued in Compliance With Article 11 of G.S.Chapter 130a Sanitary Sews a Systems ,7l L Permit Number Name ' +� ,�f'��r , �, i fY, •��.�f I Date _I_��`'�j' NO .� - 756 Location Subdivision Name Qua 114, /cam Lot No. i7 Sec. or Block No. Lot Size ZZI L House 'c/ Mobile Home - Business __ Industry - No. Bedrooms `-.P No. Baths 2 X.;�? No. in Family _ Public Assembly Other Garbage Disposal YES ❑ NO--[.r Specifications for System: Auto Dish Washer YESNO E]Auto Wash Ma^hine YES LTJ 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. Impr ments permit by __—_-- "Contact a representative of the Davie County Health De ment f anal 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 completio eleph A Number:704-634-5985. Final Installation Diagram: lh System Installed by _ MZ-14 My r- r 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. .. .. . . . .. .. 7 APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT Davie County Health Department } ✓ �' ' Environmental Health Section MARJ �g 4 P.O. Box 665 Mocksville, NC 27028 a i 1. Application/Permit Requested By 1 (GL f-Iiyt2u1 � .US% -�NC Mailing Address 40 8 &--,X , 7 /J?0 C/es✓:C, E _ Al.C, Q 70 � Home Phone 1�zqvQ- 7,S--7!Z Business Phone__99k - 7.� 7� 2. Name on Permit if Different than Above 3. Application/Permit for: General Evaluation ❑ Septic Tank Installation 4. System to Serve: lkf<Ouse ❑ Mobile Home ❑ Place of Public Assembly ❑ Business ❑ Industry ElOther ❑ Unknown 5. If house, mobile home: Subdivision V L/-1 iL J-16LGd c.J Section Lot # 7 . ❑ Basement/Plumbing No. of People ❑ Basement/No Plumbing No. of Bedrooms arwashing Machine No.of Bathrooms :;2 KV cP /� eDishwasher Dwelling Dimensions DItarbage Disposal 6. If business, industry, place of public assembly, other: Specify type No. of People Served No. of Sinks .4 No. of Commodes a 2 No. of Urinals No. of Lavatories No. of Water Coolers No. of Showers Water Usage Figures 7. Type of water supply: 044blic ❑ Private ❑ Community 8. Property Dimensions /14 C.6 1 0 7S Sewage Disposal Contractor 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes MINo 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 best oLmv knowledge, and I understand I am responsible for all charges incurred from this application. ;6�2 DATE SIGNATURE CONSENT FOR SITE EVALUATION T4 BED NE 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 onter 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 • DAVIE COUNTY HEALTH DEPARTMENT -� Environmental Health Section \ Soil/Site Evaluation NAME �� Q N C-';, �z-S DATE EVALUATED ADDRESS �� 3 �c�L�r PROPERTY SIZE PROPOSED FACIILTY _ LOCATION OF SITE �d Water Supply: On-Site Well Community Public Evaluation By:C f 1- Auger Boring Pit ✓ Cut FACTORS 1 2 3 4 Landscape position 13 -S Slope Z o - ° O - So HORIZON I DEPTH ' `B ' Texture group C L C Consistence Structure R C Mineralogy ',► 1'.t HORIZON II DEPTH 4`' 0 Texture groupC C Consistence - Structure lid $r__ Mineralogy 1 1;► HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS S-s SS RESTRICTIVE HORIZON - — SAPROLITE — — CLASSIFICATION S LONG-TERM ACCEPTANCE RATE( , C SITE CLASSIFICATION: _ EVALUATED BY: � - LONG-TERM ACCEPTANCE RATE: `1 OTHER(S) PRESENT: REMARKS: cep 1 �• 1 G�a� r � °� exc� ri� �� 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-Film 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) LT AR - Long-term acceptance rate - gal/day/ft2 DCHD(Q1-901 ■■.■■■■■■...■.■■.■..■■■■.■■■..■■■■■■■■■..■■■■■ ■.■.■.■..l. 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