292 Budk Seaford Road Lot 10-- DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTE: tissued in Compliance With Article II of G.S. Chapter 130a
Sanitary Sewage Systems Permit Number
Name Date N2 Gd E
Location
Subdivision Name j�l,= ��� 1 L– �1 Lot No. �' �� Sec. or Block No.
Lot Size I_� House Mobile Home _ Business Speculation
No. Bedrooms No. Baths > — No. in Family _
Garbage Disposal YES a NO ❑ Specifications for System:
Auto Dish Washer YES ❑, NO ❑ -
Auto Wash Machine YES E]-- NO ❑
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:
System Installed by tAK �, 1
: L" - N
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.
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
-� Davie County Health Department
Environmental Health Section
P. 0. Box 665 RECEIVED rA
Mocksville, NC 27028 DE,- s
1. Application/Permit Requested By 7Z✓ll
Mailing Address 53i ` 1o0-ks
Home Phone i2- �)G Business Phone
2. Name on Permit if Different than Above
3. Property Owner if Different than Above
4. Application/Permit For: LC) General Evaluation ZZ/Tank Installation
5. System to Serve: House u Mobile Home 0 Business
L Industry Others' L�, ,, �,,4L�, Unknown
6. If house, mobile home: Subdivision ��QA� a fA `see. , Lota
No. of People T Dwelling mansions 3+X S 4 /
No. of Bedrooms 3 Basement/Plumbing
No. of Bathrooms Basement/No Plumbing
ashing Machine �shwasherGrarbage Disposal
7. If business, industry, other: Specify type
No. of
No. of
No. of
No. of
People Served No.
Commodes No.
Lavatories No.
Showers
8. Type of water supply: g. -Public 0 Private Q Community
9. Property Dimensions
10. Sewage Disposal Contractor
of Sinks
of Urinals
of Water Coolers
11. Do you anticipate additions/e�xp,%a ions of the facility this system is
intended to serve? 0 Yes " s
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.
This is to certify that the information provided is correct to the
best of my knowledge, and I understa d I a rfispons'ble for all
charges incurred from this applica
/A- 6 - 20 _
Date Signature
Directions to Property:
4
DCHD (10-89)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
NAME �J;J
ADDRESS S P cc• o
PROPOSED FACIILTY R0_0`sL_
DATE EVALUATED I - 1 -90
PROPERTY SIZE q n
LOCATION OF SITE
Water Supply: On -Site Well Community Public V
Evaluation By �,�i_ Auger Boring Pit Cut
FACTORS
1
2
3
4
Landscape position
Slope 7,
-IK °
C>-
(:�) - b
6 -
HORIZON I DEPTH
n
't
21)
Texture group
0 L
Q L
Consistence
-'
Structure
Mineralo
' I
',)
It
HORIZON II DEPTH
Lt 12
L4 1''
U"
Texture groupC
C
L
Consistence
-
Structure
k
3
,
Mineralogy
fitI
I
HORIZON III DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
.S
S s
S5
.SS
RESTRICTIVE HORIZON
--
—
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE
"I
i
SITE CLASSIFICATION: ` R �'�> EVALUATED BY: I r�---)- 9 V
LONG-TERM ACCEPTANCE RATE: �4 OTHER(S) PRESENT:
REMARKS:
LEGEND
Landscape Position
R -Ridge S -Shoulder L -Linear slope FS -Foot slope N -Nose slope
CC -Cons nip 0n.,P 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)
MONROE
EMEMME
NMI
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