109 Lakeside Drive Lot 5-p
`�.. DAVIE COUNTY HEALTH DEPARTMENT
r IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION. �
*NOTE: Issued in Compliance With Article II of G.S. Chapter 130a
Sanitary Sewage Systems ,; �`f,;_ i✓! Permit Number
Namel" " r,`,?cl 5 ��.i� ,%�—// Date Z�- -.i N2 7 3 E7 4
Location '" !�?` h�f�,' %" �� r' l/� vim.+ ,iq""�" _ .` r✓i i 1,%_� �✓
t
Subdivision Name Lot No. Sec. or Block No.
Lot Size_ House — Mobile Home Business _— Industry
No. Bedrooms —.No. Baths e�— No. in Family __ Public Assembly Other
Garbage Disposal YES NO ❑
Specifications for System:
Auto Dish Washer YES NO ❑ f.
Auto Wash'Ma^hine YES NO ❑ SGCry
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 plan .orthe intended use change.
R
Improvements permit by —!A//
*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�a�,)
I
1
U S I-*
Fn ll
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.
1. Application/Pi
Mailing Addre
Home Phone
r
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section
P. OBox
Mocksvill 2e, NC 27028
Iq
2. Name on Permit if Different than Above
3. Application/Permit for:
IX General Evaluation
eptic Tank Installation
4. System to Serve: d House ❑ Mobile Home ❑ Place of Public Assembly
❑ Business ❑ Industry ❑ Other ❑ Unknown
5. If house, mobile home: Subdivision ��� n �\Le-� Section Lot #
No. of People
No. of Bedrooms
l�
No. of Bathrooms
Dwelling Dimensions
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
ff Basement/Plumbing
❑ Basement/No Plumbing
9 Washing Machine
W Dishwasher
[;�Garbage Disposal
No. of Showers Water Usage Figures
7. Type of water supply: 11( Public ❑ Private ❑ Community
8. Property Dimensions 1 alne, Sewage Disposal Contractor
9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes Ed No
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: `cJ� �_ (�� JOL `� O Orae-- 5 0
No
This is to certify that the information provided is correct to Lt
my knowled derstand I am responsible for all charges
incurred from this application.
�I ZZ 42 '47
DATE 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 D vie ounty Health Dep rtment t ent r u on abqyedescribed
property located in Davie County and owned by c
to conduct all testing procedures as necessary to deterinipe said site's suit or a nd a orption s wage treatment
and disposal syste .
- 19 CJ I
DATE SIGNA R
DCHD (12-90)
1
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
NAME
ADDRESS
PROPOSED FACIILTY�!/�
DATE EVALUATED
PROPERTY SIZE C
LOCATION OF SITE�yA�-S
Water Supply: On -Site Well Community Public 2/
Evaluation By: Auger Boring Pit Cut
FACTORS 1
2 3 4
Landscape position 4L
Sloe %
HORIZON I DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH
Texture group CIO
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
!
SITE CLASSIFICATION: R __(
LONG-TERM ACCEPTANCE RATE:
REMARKS:
DCHD(01-901
EVALUATED BY:
OTHER(S) PRESENT:
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)
LTAR - Long-term acceptance rate - gal/day/ft2
Davie County Nealtkr De artment
.dame Nealtfi Aen
and y cy
210 HOSPITAL STREET/ P.O. BOX 665
MOCKSVILLE, N.C. 27028
PHONE: (704) 634-5985
January 6, 1992
Carl W. Moser
x239 Linda Dr.
Winston-Salem, NC 27106
Re: Site Evaluation
Greenwood Lakes/Lakeside Dr.
Dear Mr. Moser:
As requested, a representative from this office visited the aforementioned
site on January 21 1992. The site was found provisionally suitable for the
installation of ground absorption sewage system.
If you have any questions, please feel free to contact this office.
Sincerely,
ABY.- Foy& L�l
Robert B. Hall, Jr., R.S.
Environmental Health Section
RH/wd
Enclosure
cc: Gray Potts (01-09-92)