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254 Potter's Ridge Dr Lot 6 DAVIE COUNTY HEALTH DEPARTMENT ;F.;� i1. IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION 'NOTE:Issued in Compliance With Article I I of G.S.Chapter 130a �-S-,janniittary Sewage Systems Permit Number Name �' ' 1lrl v ?//r`- ;. , ,�; �— Date �L< % /_S N2 8165 Location %. d '� Subdivision Name "i S/, - � r ty6crNo. Z Sec. or Block No. Lot Size House J Mobile Home ---_ Business __ Industry No. Bedrooms — No. Baths � J�1— No. in Family ? — Public Assembly Other Garbage Disposal YES ❑ NO Specifications for System: Auto Dish Washer YES NO ❑ �'��1�^, ��%(�, ,,� ' Auto Wash Ma^hine YES g 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 ATTENTION: YOUR SEPTIC SYSTEM CONTRACTOR MUST SEE THIS PERMIT/LAYOUT BEFORE INSTALLING THIS SYSTEM. q0 dd � �► ��i,- 1 10� �� log i 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 C�t"I Z.;.� � S-J a0 J 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. APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT _ Davie County Health Departmentf Environmental Health Section P. O. Box 665 Mocksville, NC 27028 1. Application/Permit Requested By n A D 4y") Mailing Address /Zo A,n 6 11r Gn - Home Phone h,? f�✓�GGfs v�/{� /V C 7D�- Business Phone 2. Name on Permit if Different than Above 3. Application for: d General Evaluation O eptic Tank Installation Permit 4. System to Serve: L.d'House ❑ Mobile Home ❑ Place of Public Assembly ❑ Business ❑ Industry ❑ Other ❑ Unknown 5. If house, mobile home: Subdivision PCnref-, 17,E r)!5 e- Section Lot # ❑ Basement/Plumbing No. of People 3 2�1asement/No Plumbing No. of Bedrooms -3 EKVashing Machine 1 No. of Bathrooms ashwasher Dwelling Dimensions l 00 - 6�� 6yo S q. 1-T, ❑ 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 ❑ Private ❑ Community 8. Property Dimensions S "' Sewage Disposal Contractor 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes 0-IQo 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: 60 0"7- *a n /Z J. l9 F�G✓ ,y0 v mss l�wy 0 / yv i0A." % PV1 - 0r1 Pine v ,.//G lZo� • (,o ,epro�, '/v vr� . /e y-U r le- r--t- /-0+ tG0+ �" 6 This is to certify that the information provided is correct to the best of my knowledge, and I understand 1 am responsible for all charges incurred from this application. DATE SIGNATURE CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY Faondodisposal ECK ONE: ❑ 1. 1 OWN the property. ❑ 2. 1 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 system. DATE SIGNATURE DCHD(1193) DAVIE COUNTY HEALTH DEPARTMENT • Environmental Health Section Soil/Site Evaluation q NAME DATE EVALUATED 2 F ADDRESS S p"�-Q PROPERTY SIZE PROPOSED FACIILTY b1N'-� \ LOCATION OF SITE r7Ti_TL-S R I p 7� Water Supply: On-Site Well Communjty Public Evaluation By:�'�Auger Boring Pit ✓ Cut L� FACTORS 1 2 3 4 Landscape position S S" Slope 7. 0 ' � ° HORIZON I DEPTH 0 " W, Texture group C L Consistence �� i== Structure C _ C_ I~ Mineralogy HORIZON II DEPTH b " 3G, Texture group e-1 Consistence F T Structure P K MineralogyI I HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS <S .5-s RESTRICTIVE HORIZON — SAPROLITE -- CLASSIFICATION p 5 l S. LONG-TERM ACCEPTANCE RATE , y , SITE CLASSIFICATION: ��' EVALUATED BY: LONG-TERM'ACCEPTANCE RATE: \\A PRESENT: REMARKS: Q 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 r: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 watet' 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 ii ■.■■■■■■E.■■■■..■■.......■.■.....■E.■■■E■�■■■■■■'■E■N■■■.■■■■u'�i■■ iiiiiiiiii�.iiiiiiiiiiisiiiiiiiiii=iiiiiiii■iii■iiii=iiiiiiiiiii=■ iiiiiiiiiiiiiiiiiiiiiii■i�iiiiii�ii�■iiiii�iiiiiiiiiiiiiiii� ONE ■..■■■......■.......■.■...■......■.0■■■..■...eu■e.■=NOON■■■■■■e. .................................................. ............... ................................ ....................... ........ iiiiiiiiiiiiiiiiiiiiiiiiiieiiiiiiiiiiiii�iiiiiii�■■MEN=NEENE■MMEMENO MEMO ■■■.■■■■■.■.e.It■.■...■.■■■■■■.■.■E■.■s■■■■■tl■e■■ e■■■■■■■E■■■.■■■■ ..............�..................v..��.. . ....... ....... ..■.■.■■ ..............��....................... ..... . ...■..■■.■■... :.ENO C:CC ..I.I..�_..■...� .. . .. ...... ..............■..........■■.��iC,.l...■■.� ■■■O E■■■..e■■■■ E.N■ ■■..■■■■.■■■■■n■■u■■■■■.■■.■�■■■■■■■■ i■ uu■■ ■■■■.. ■ ■.■.......■■■■11■■■■...■..■■■ 117►/.■■.�..■■.■■■ ■ ■■■■■■■ ■e■■■■ ■.■■■■■.■■■■■■■■■■■■■■■■■■■a■!N■■■e. ■e■■■■■.I■■■ ■■■■■■NE■■■.■■■ ■.■■■.■■■.■■■■.■■ ■■.■■.■.■■■■■■ NOONn NOON ■■ .■■.■..■...■.■ ■.■.■u■■■.■■■■■■=■.e■■■.■.■■e■E■■■E=r.■ ■■�■u WE ■E..E■■u■■■■■ :::MEM: MEN o:::::.::::::::::::::' ::: No '='MM':M:MMCMME ................................ ■......�..■■.■■■u■■■■■.■.■ NONE ■■..u■■■■■■■■■■■■■■■■Qoa.■■■■a. NOON■■■ ■■.■■■■■■■■■■■■■■■■■MINNUMMUMMOMMUMMENN IIMMMMMMMMIMMMMMMMM ■■■■ ■■.■.■.■.■...■.■■■■■■■■■■ ..■■■■..■..u.. ■........■■..■...■......CN..■..0..■■.■■■ .....■■■....■........... ................................ ................................ ...................................... ........................... .................................................................. .................................................................. ■■■■ ■■■■.■u.......■.....■...■■M...........................■.... DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation NAME _�AQUI2g.? DATE EVALUATED �� ADDRESS PROPERTY SIZE PROPOSED FACIILTY �� LOCATION OF SITE B,Q' Water Supply: On-Site Well _ Community Publicy Evaluation By: Auger Boring !/ Pit Cut FACTORS 1 2 3 4 Landscape position L41 Sloe Z HORIZON I DEPTH �� « Texture groupG L Consistence Structure Mineralogy HORIZON II DEPTH Texture group r rG Consistence ; Structure k Mineralogy HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: EVALUATED BY: /�t LONG-TERM ACCEPTANCE RA E- j HERS) P ESENT: REMARKS: (fie/S` O i Z,�Z LEGEND Landscape Position R-Ridge S7Shoulder 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-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 3C--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 ■...■■■■.■■._■■■MOOR■■N■■■■■■■■■■.H.■...■■■■■■■ ■■■■.■■■.■...■ ■ ■■.■■■■....■.■.......■■■.■..■.■■..■..■■■■■■■■■■■■■■■■.■■■■■■■■■■.. ...........................................�...■.... ■■■■■N■■■■.■■ ................................... ...... ........ ....■.■■.■... ................................ ................. ■.■N■■...RICE■ ................................ .■■■N■NN■N■■OM■..=....■■■N■■■■NN ::■:moms:No so:: ■.■■..■■.■■■.■■■■.■■■■.■....■N.�■.■.■/INM■■■■■■ ■■MEM■ME.�■M■MEMO■EM ■...■■■■■.■■■■■.■■..■■.■■■■r�Mn■r�r,��rir�;��►■N:■■■s ■ssm■■■:■■■■N■N':no OMEN m ::::::::::::::i%ii'■i::::::::::::::::::::::Mi■:moo:0 MEMO.':::0 EEO MOM::::'.�'■:::■::: MONO nMMMMMMMMM =s ■MOOR.■H■■■■■■..■■■.■EH..■■..■ MOOR■HH .:■■HHM■■■.■■■■E:■■■ I NOON ........N■■N■E■MNNR■ON■.ME■EMM.■MM.NMMN■O■N■ ■ ■■■■ ■EN■N■ M MIEN M in MEE MMEMMEM ME No ME MONSOON .■■.:..............................■■. 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