171 Four Corners Road Lot 3. 7W— ...,,..,"4 Tai V94 _ .,r- __ —... --- w -.---.-c_-..-+.�v.✓.rr'K. .r"_d�vr-u (�-�..0 � .,dX/+:-j+���'✓v r-
17
='�`" DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
�-*'NOT_ E: Issued in Compliance With Article 11 of G.S. Chapter 130a
,�nitary Sew�g�g Systems Permit u
�P//IJ a rX J 7�n /r� c: t Yr ~s 'mss ` i>�'�. /1 A99'-�
Ngme D Ie _ No
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Location
Subdivision Name Lot No. Sec. or.'Block No.
• % or .
Lot Size House Mobile Home _ Business Speculation
No. Bedrooms No. Baths —�_ No. in Family
Garbage Disposal YES NO ❑ Sp ci ic, �o stem:
S
Auto Dish Washer YES NO ❑�" �y
Auto Wash Ma :hive YES NO ❑ tGGS/���� s t
Type Water Supply _
*This permit Void if sewage system described below is not installed within 5 years from date of issue. k
This permit is subject to revocation if site plans or the intended use change.;
t
r ,
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
F
ov
o
y
C pletion 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.
�w, �a`1 APKICATION FOR SITE EVALUATIONIIMPROVEMENTS PE !2 2 /7 2
Davie County Health Department 15 L5 V LS
Environmental Health Section
P. 0. Box 665SEP 2
Mocksville, NC 27028 9
1. Application/Permit Requested By. `� �G"
Mailing Address S " Home Phone %Qin q
I\"Q�8 IA' ��. N C— a 7 OD-� Business Phone
2. Name on Permit if Different than Above
3. Application for: ❑ General Evaluation # Septic Tank Installation Permit
4. System to Serve: XII House ❑ Mobile Home ❑ Place of Public Assembly
❑ Business ❑ Industry O Other ��o'��� ❑ Unknown
5. If house, mobile home: Subdivision __ /--Vu%�l�"��.��G�T�.�' Section Lot #
No. of People 2
No. of Bedrooms 3
No. of Bathrooms 2 la
Dwelling Dimensions 36� x 10 mn't>3 Leel
6. If business, industry, place of public assembly, other: Specify typo
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.
T Type of water supply: 1 Public ❑ Private
8. Property Dimensions Ct - 4?` / 0)- Sewage Disposal Contractor
Z Basementnumbing
❑ Basement/No Plumbing
.14 Washing Machine
9 Dishwasher
O Garbage Disposal
9. Do yop anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes No
If yes, what type?
O 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:
}, Cfl o 1 Nor fid, `%o t}wx( ?01 T•iR o n gD 1 -7/. n a,- TIL-
Y)
I Ln Four &piers 12d Frsr 1)ousc orn LeFT.
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.
93 dfe��
DATE SIGNATURE
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 systeq
DIATE L SIGNATURE
OCHO (1193)
* DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
NAME
ADDRESS
PROPOSED FACIILTY
DATE EVALUATED o!�o --7 -�3
PROPERTY SIZE �%frfC
LOCATION OF SITE 2
Water Supply: On -Site Well Community Public
Evaluation By: Auger Boring Pit 11__*� Cut
FACTORS
1
2
3
4
Landscape position
A,—
Slope
Sloe
HORIZON I DEPTH
P''
''
6 -
Texture rou
Texture
L
S'L
fG
Consistence
Structure
Mineralogy
HORIZON II DEPTH
�'�/�
-5'"
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
ITT-
�"
�7
LONG-TERM ACCEPTANCE RATE
SITE CLASSIFICATION: !r/:cr , 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
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
DCHD(01-90)