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221 Montclair Drive`'moo 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 it Name Clifford E. brown, Po'b •j1, Coo 1ec"r_c, Date !�[ �. y " N2 7966 XC -27014 . Location 15SL-_; lit. on Baltimore Rd.; (jo 2 Miles turas les t; C7o througli Baltimore 11eic hts and across cut -de -sac onto private road; Site on left side of road Subdivision Name Lot No. Sec. or Block No. Lot Size i acre---- House — '` Mobile Home ---_ Business -- Industry No.. Bedrooms *3— No. Baths — L—_ No. in Family 2 — Public Assembly Other Garbage Disposal YES Q NO p Specifications for System: Auto Dish Washer YES ® NO Q '4 Auto Wash Ma^hine YES Q NO u Type Water Supply pub 'This permit Void if sewage system described below is not installed within 5 ye rs 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 PERM IT/LAYOUT�EFORE INSTALLING THIS SYSTEM. I-) Improvements permit by —! 'Contact a representative of the Davie County Health Department for final inspection oft is sy t 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: 704-634-598 .v Final Installation Diagram: System Installed l rL X00 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 PE ECEU l ED Davie County Health Department -61994 }� Environmental Health Section D P. O. Box 665 Mocksville, NC 27028 _______________ 1. Application/Permit Mailing Address By Home Phone 4;:�?TC--2,2� Business Phone 2. Name on Permit if Different than Above X' 3. Application for: General Evaluation ❑ Septic Tank Installation Permit 4. System to Serve: &'rlouse ❑ Mobile Home ❑ Place of Public Assembly ❑ Business ❑ Industry 0 Other ❑ Unknown 5. If house, mobile home: Subdivision Section Lot # ❑ Basement/Plumbing No. of People [Ertasement/No Plumbing No. of Bedrooms 3 ©'Washing Machine . No. of Bathrooms Z Et -Dishwasher Dwelling Dimensions ❑ Garbage Disposal 6. If business, industry, place of public assembly, other: Specify type No. of People Served No. of Commodes No. of Lavatories No. of Sinks No. of Urinals No. of Water Coolers No. of Showers �/ Water Usage Figures _ 7. Type of water supply: 1Q Public ❑ Private 8. Property Dimensions Jac, Sewage Disposal Contractor 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? , ❑ Yes ❑ No 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: ey This is to certify that the information provided is correct to the best of my knowledge, and I understand I am responsible for all charges incurred from this application. 9 _ s_ �. DATE SIGNATURE CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY MUST CHECK ONE: 1. I 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. g-!�-=iy DATE DCHD (1/93) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation NAME 60'0') ADDRESS / PROPOSED FACIILTY DATE EVALUATED PROPERTY SIZE LOCATION OF SITE/ ii ✓f Water Supply: On -Site Well Community Public Z ---- Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3 4 Landscape position L Slope Z '- HORIZON I DEPTH Texture group Consistence Structure MineralogX HORIZON II DEPTH f" •Y£ Texture group Consistence / Structure 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 `L I, SITE CLASSIFICATION: EVALUATED BY: LONG-TERM ACCEPTANCE RATE: - OTHER(S) PRESENT: REMARKS: 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 Moist VFR-Vo.-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 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 .................................................................. ................................ ................................ ........................... ................... .................. 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