4472 NC Hwy 801N Lot 7DAVIE COUNTY EALTH DEPARTMENT
IMPROVEMENTS PERMIT -AND CERTIFICATE OF COMPLETION
•
*NOTE: Issued in Compliance With Article 11 of G.S. Chapter 130a
Sanitary Sewage•Syste�ms Permit Number
Name ��0' _e r"'�-�;. PaB �s', �oo��EmDate ;9 N2 7 3 4 6
Location' !� ' �.� .�? �' Y tr I Id r y Vy+s T/ e/ � u � / ON, � -
_N TI s
Subdivision Name t -No: Sec. or Block No.
Lot Size -� House Mobile -Home Business _— Industry
No. Bedrooms. No. Baths - No. in Family _ Public Assembly Other
Garbage Disposal YES ❑ NO Specifications for System:
Auto Dish Washer YES ❑ NO
Auto Wash Ma^hine YES Ql"NO ❑ t, �
Type Water Supply
t
'This permit Void if sewage system described below isnot installed within 5 years from date of issue.
This, permit is subject to revocation if site plans or the intended u ange.
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Improvements permit by —ZIZ4 `
*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
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Certificate of Completion 1/\\�l4 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.
r t APPLICATION FOR SITE EVALUATION/IMPROVEMENT:
Davie County Health Department
Environmental Health Section
P. O. Box 665
Mocksville, NC 27028
1. Application/Permit Requested By _
Mailing Address )VO to
/11 / c 14Ar.,c.- GcPit-t rl; AN/tWN
2. Name on Permit if Different than Above
3. Application for:
1@ L50 V L5 �
G,S G00LF- E MF E Nc Home Phone 'Z8T4 -2391 MW&f-
Phone `2 24 - 01 0Z r�
❑ General Evaluation Septic Tank Installation Permit
4. System to Serve: ❑ House d Mobile Home ❑ Place of Public Assembly
❑ Business ❑ Industry ❑ Other ❑ Unknown
5. If house, mobile home: Subdivision/f� �/'G � a Section f�t #
❑ Basement/Plumbing
No. of People I ❑ Basement/No Plumbing
No. of Bedrooms 3 2- Washing Machine
No. of Bathrooms ❑ Dishwasher
Dwelling Dimensions 141X 70 ❑ 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: ❑ Public ❑ Private ❑ Community
8. Property Dimensions 13 /,/�(/' Sewage Disposal Contractor
9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes e'Ro
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:
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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.
DATE SIGNATURE
CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY
MUST CHECK ONE: Q 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.
DATE SIGNATURE
WHO (11M
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
NAME
ADDRESS
PROPOSED FACIILTY
DATE EVALUATED
PROPERTY SIZE 3�6
LOCATION OF SITE
Water Supply: On -Site Well t'___ Community
Public
Evaluation By: Auger Boring , / Pit Cut
FACTORS
1
2 3
4
Landscape position
L
Slope %
`'
HORIZON I DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH
''
3 • `'
�`�
Texture groupC
Consistence
r
Structure
91) /,
/i
Mineralogy-
HORIZON III DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
I 7K
LONG-TERM ACCEPTANCE RATE
SITE CLASSIFICATION: EVALUATED BY: Wa G/
LONG-TERM ACCEPTANCE R TE:
REMARKS:
DCHD(01-901
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