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518 Deadmon Rd Lot 6" DAVIE COUNTY HEALTH DEPARTMENT lY /� IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION I *NOTE: Issued in Compliance With Article I I of G.S. Chapter 130a Sanitary Sewage Systems Permit—"-u—"-uber Name `-�-_�� ,, Date , Np � �� Location Subdivision NameLot No. Sec. or Block No. U Lot Size ' House Mobile Home _ Business _— Speculation `3. v. No. Bedrooms No. Baths No. in Family _ i Garbage Disposal YES p NO (] Specifications, for -System: Auto Dish Washer YES [] NO p '` Auto Wash Ma^hine YES [ NO p 0 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. 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:LF- E14 em Installed by-T`,r� e r L V J 1 ; / - �, Q 4 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. •M h APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT Davie County Health Department REF!1�7n? Environmental Health Section IE P.O. Box 665 Mocksville, NC 27028 JU1 / -------------- 1. Application/Permit Requested By Mailing Address %% cc�ff �Sa 3�DS /UC� `Ile- .& C, 7 HomePhone `/—� %� �1/ Business Phone 2. Name on Permit if Different than Above �/ 3. Application/Permit for: ❑ General Evaluation L" Septic Tank Installation 4. System to Serve: ZHouse ❑ Mobile Home ❑ Place of Public Assembly ❑ Business ❑ Industry ❑ Other ❑ Unknown 5. If house, mobile home: Subdivision �l �2�Z �z Section Lot # J6 No. of People _ No. of Bedrooms No. of Bathrooms Dwelling Dimensions 2,6 / ,VL. / t 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 ❑ BasemenUPlumbing ❑ Basement/No Plumbing 03"Washing Machine Dishwasher ❑ Garbage Disposal 7. Type of water supply: EnPublic ❑ Private ❑ Community 8. Property Dimensions —/ Sewage Disposal ContractorTom, 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes 0 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: 0 So v �`� � p�u ��ia n (/71i1. %_o 00 5 This is to certify that the information provided is correct to the best of my knowledge, incurred from this application. de �, -lyl"e, G DATE SIGNATURE I am responsible for all charges 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 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 DCHD (12-90) k DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation l NAME DATE EVALUATED z/.-/? ADDRESS PROPOSED FACIILTY PROPERTY SIZE / LOCATION OF SITE Ae6;420 - Water Supply: On -Site Well Community Public- Evaluation ublic_Evaluation By: Auger Boring // Pit , / Cut FACTORS 1 1 2 3 4 Landscape position Slope % �— HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH Texture group Consistencer �7 Structure %I S�4 1 7 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 - SITE CLASSIFICATION: EVALUATED BY: ZZ 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 -Film 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 APPLICATION FOR SITE EVALUATION/ IMPROVEMENTS. PERMIT Davie County Health Department Environmental Health Section ............ P. 0. Box 665 Mocksville, N.C. 27028 CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED. Home Phone Z ' _ — Q Do? 1. Permit Requested By U �f= Dm a�t' Business Phone 2. Address o O c iC ✓ �//i= h _C vZ ?o �- 3. Property Owner if Different than Above Address 4. Permit To: a) Install Alter Repair b) Privy Conventional Other Type— Ground ype Ground Absorption c) Sub -Division Sec. Lot No. �L v 5. System used to serve what type facility: House Mobile Home Business Industry Other 10 u p (t '. API, b) Number of people - 6. a� If house or mobile home, state size of home and number of rooms. House Dimensions Bed Rooms Bath Rooms Den w/Closet b) If Business, Industry or Other, State: Number of persons served What type business, etc. Estimate amount of waste daily (24 hours) 7. Number and type of water -using fixtures: commodes I urinals garbage disposal lavatory showers I washing machine I dishwasher I sinks 8. a) Type water supply: Public Private Community b) Has the water supply system been approved? YesL�No i 9. a) Property Dimensions I a 0 X %- 0 0 b) Land area designated to buildirq site /q.It — c) Sewage Disposal Contractor I) A V r (- 5,132 /1c =Wk�m 10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve? What type? This is to certify that the information is c rect to the best of my knowledge. Date Owner Signature OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS Allow 5 days for processing Directions to property: �o( DCHO (8.82) SCq -e -7-411*17 l Address DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Box 665 Mocksville, N.C. 27028 SOIL/SITE EVALUATION Date b � (3- 6 Lot Size ) D Q �/ q 0 Of FArTnR.R ARFh 1 1 AREA 2 AREA 3 AREA d 1) Topography/ Landscape Positions- 9) C.�� PS S PS S PS U U U ?) Soil Texture (12-36 in.) Sandy, Loamy, Clayey, (note 2:1 Clay) A-1 S �� S PS S PS U U U U 3) Soil Structure (12-36 in.) Clayey Soils (.f S �, f, P$' S PS S PS U `t�� U U I) Soil Depth (inches) (t� S PS S PS U U U U i) Soil Drainage: Internal SS PS S PS S PS U" U" U U External SS S PS S PS v U U U i) Restrictive Horizons � Available Space S QD S PS S PS U U U U 1) Other (Specify) S PS U S P S PS U S PS U Site Classification U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable Recommendations/Comments: Described by Title Date SITE DIAGRAM DCHD (6-82)