162 Bugle LaneV%0
` DAVIE COUNTY HEALTH DEPARTMENT
I IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION 3 •�J
*NOTE: Issued in Compliance With Article II of G.S. Chapter 130a
Sanitary Sewage Systems r, « Permit Number
\ �� �. - 7
Name � � . � :. � jy c. \ Date N2 7021
Location �`"� l� �:> �;�� � "1 "� - � ��,\ � � �� _ � , \\ o ��� �• �! 1 �
Subdivision Name ` \ `�`' \�''- VIE Lot No. � "' ��sO�Sec. or Block No.
Lot Size House Mobile Home _T Business -- Speculation
No. Bedrooms ~' No. Baths — No. in Family
Garbage Disposal YES ❑ NO [:1 Specifications .for S stem: _
Auto Dish Washer YES [� NO E]/ fs � Ql�
Auto Wash Ma shine YES d NO ❑, -: ` x _ r
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.;
ly
J
. � y
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. or 1:00-1:30 P.M. on day of completion. Telephone Number 704-634-5985.
Final Installation Diagram:
System Installed by
Ev)66
N coo
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.
FR1_ Ia'.ao
` APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT M fA
Davie County Health Department
Environmental Health Section U,'f A'+
P. O. Box 665 R'¢
Mocksville, NC 27028 FEB — 2 1993
1. Application/Permit Requested By
Mailing Address L/
Home Phone q 749 Business Phone
2. Name on Permit if Different than Above
3. Application/Permit for: ❑ General Evaluation ET Septic Tank Installation
4. System to Serve: eHouse ❑ Mobile Home ❑ Place of Public Assembly
❑ Business ❑ Industry ❑ Other ❑ Unknown
5. If house, mobile home: Subdivision Section Lot #
❑ Basement/Plumbing
No. of People 5 ❑ Basement/No Plumbing
No. of Bedrooms 3 121 -Washing Machine
No. of Bathrooms 2 2 -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: L7 Public ❑ Private
8. Property Dimensions -V &r"a"S Sewage Disposal Contractor
9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes
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: Mp/ i4 ��
k;���
This is to certify that the information provided is correct to the be f my k
incurred from this application.
c
42-7-2
DATE
SIGNATURE
I am responsible for all charges
CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY
MUST CHECK ONE: E�<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 he Davie County alth Department to enter upon above described
property located in Davie County and owned by �
to conduct all testing procedures as necessary to etermine said site'' suitability for a ground absorption sewage treatment
and disposal system. , Q , �1
DATE Z; SIGNATURE
DCHD (12-90)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
NAME _�� S 1J l; �� 1 eS
ADDRESS
's A lr A
PROPOSED FACIILTY
DATE EVALUATED ____� S ' 93
PROPERTY SIZE 4 (31�
LOCATION OF SITE
Water Supply:
On -Site Well
Community
Public
Evaluation By:e -
Auger Boring
Pit
Cut
S
Sloe %g
FACTORS
1
2
3
4
Landscape position
S
S
Sloe %g
S
HORIZON I DEPTH
Texture groupS7z
1_
CL
C
C L_
Consistence
=�
Structure
Q
C
Mineralogy
HORIZON II DEPTH
Texture group
C
C
Consistence
IF L
Structure
�,@)r_
e �F_
Mineralogy
HORIZON III DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
SS
$S
_C5-
sRESTRICTIVE
RESTRICTIVEHORIZON
—
SAPROLITE
CLASSIFICATION
S
S
S
LONG-TERM ACCEPTANCE RATE
,y
SITE CLASSIFICATION: �� S EVALUATED BY: \
LONG-TERM ACCEPTANCE RATE: i OTHER(S) PRESENT:
REMARKS: - N" '
LE END
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 -Finn 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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OMEN
NONE
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