315 Buck Seaford Road Lot 7r.,
w DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION 1
- *NOTE: Issued in Compliance With Article I I of G.S. Chapter 130a
Sanitary Sewage Systems
Permit Number
Name
Date U (_
NO 'y
Location,
Subdivision Name \ , Y'�
Lot No. / Sec. or Block No.
Lot Size House br
Mobile Home — Business _—
Speculation
No. Bedrooms No. Baths �'
f
No. in Family —
Garbage Disposal YES ❑ NO p'
Specifications for System:
Auto Dish Washer YES ❑ NO ❑�
P,;
Auto Wash Machine YES Ell NO ❑
_I
7 (-) � , �i
}
Type Water Supply's w
*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.
t
C:
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
,U
R
Z !G
Certificate of CompletionDate
-
*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.
APPLICATIQN FOR SITE EVALUATION/IMPROVEMENTS PERMIT
' Davie County Health Department
Environmental Health Section
P. 0. Box 665 RECEIVED SEP 17 IM
Mockaville, NC 27028
1. Application/Permit Requested By LV _
Mailing Address Yo. CJS X99 Yw, I�
Home Phone 63 el - 74l a 4 Business Phone ( 3
2. Name on Permit if Different than Above /11-0
S. Property Owner if Different than Above L,`10 Q"
4. Application/Permit For: General Evaluation B-S/Tank Installation
5. System to Serve: [House u Mobile Home 0 Business
L] Industry u O��t��hJjer Unknown
6. If house, mobile home: Subdivision 7.t/A,Z' oES'TNTfS Sec. Lot# 7
No. of People Dwelling Dimensions
No. of Bedrooms .3 ] Basement/Plumbing
No. of Bathrooms :;L 7 Basement/No Plumbing
(,Washing Machine, J Dishwasher 0 Garbage Dispusai
7. If business, industry, other: Specify type
No. of People Served
No. of Commodes
No. of Lavatories
No. of Showers
No. of Sinks
No. of Urinals
No. of Water Coolers
S. Type of water supply: 'VYF�ublic 0 Private a Community
9. Property Dimensions t , a e 9 o -e- -
10. Sewage Disposal Contractor
11. Do you anticipate additions/expansions of the facility this system is
intended to serve? r Yes L"o
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 trig_
best of my knowledge, and I understand I am responsible for all
charges incurred from this application.
Date Si nature
Directions to Property:
%
DCHD (10-89)
DAVIE COUNTY HEALTH DEPARTMENT
ENVIRONMENTAL HEALTH SECTION
SITE EVALUATION CONSENT FORM
1. Complete the form below and return to the Davie County Health Department.
2. Carefully follow the procedures as outlined in the enclosed "Information Bulletin."
NOTE: THE ABOVE MUST BE COMPLETED BEFORE A SANITARIAN WILL BE ABLE TO
BEGIN THE REQUESTED EVALUATION.
DETACH HERE AND RETURN TO: Davie County Health Department, Environmental
Health Section, R O. Box 665, Mocksville, N.C. 27028
Davie County Health Department
Environmental Health Section
Site Evaluation Consent Form
LOCATION OF PROPERTY: DATE RECEIVED
P4(office use only)
yes no 1. 1 am the owner of the above described property.
yes no 2. 1 am not the owner of the
n� above �/Io�wners<me
described property, however, I certify that I
have consent from lJc�ta� owner to obtain a
site evaluation by the Davie County Health Department for the purpose of
determining the suitability for a ground absorption sewage treatment and
disposal system.
yes no 3. 1 hereby give consent to the authorized representative of the Davie County
Health Department to enter upon the above described property and conduct all
testing procedures as necessary to determine its suitability for a ground
absorption sewage treatment and disposal system.
q- /?-9c)
DATE
�r
4. 1 hereby authorize the Davie County Health Department to release site
evaluation results from the above described property to the following:
— Owner only
Owners designated representative
Anyone requesting results
— Only those listed below
DATE
DCHD (11 /84)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
NAME �1J CAv cr �n�n S�
ADDRESS S A cc�4
PROPOSED FACIILTY
Water Supply: On -Site Well
DATE EVALUATED rl - n 7 d
PROPERTY SIZE C� • 2� pp
LOCATION OF SITE
Community Public ✓ daclde�
Evaluation By: �.� L� Auger Boring l,/ Pit Cut
FACTORS
I
2)
Q0
Landscape position
Sloe %
tismm
HORIZON I DEPTH
$
S
0 y
Texture group
S 0.s
C
Q
Consistence
F L
Structure
C k
0 Q
G
Mineralogy
i1
%4.11°
HORIZON II DEPTH
40
0
901,
0
Texture group
Consistence
Ir T
F T
Structure
Mineralogy
: I
I 1
; /
/
HORIZON III DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
-
�-
--
-
SAPROLITE
CLASSIFICATIONS
S
S
S
LONG-TERM ACCEPTANCE RATE
` t C
. s - yo
��_ t� .cam 9,p
SITE CLASSIFICATION: \1 EVALUATED BY:
LONG-TERM ACCEPTANCE RATE: - 3� y.O 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(01-901