325 Buck Seaford RoadDAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTE: Issued in Compliance With Article II of G.S. Chapter 130a
Sanitary Sewage Systems
Name ,..• Date
Location /
•moi 'i �- �l
Permit Number
No 7140
Subdivision Name Lot No. Sec. or Block No.
Lot Size Houseyr Mobile Home � Business __ Speculation
V ' /7: —
__s
No. Bedrooms __.No. Baths _ No. in Family _
Garbage Disposal
Auto Dish Washer
Auto Wash Ma :kine
Type Water Supply
YES NO ❑
YES NO ❑
YES* NO ❑
Sppcifications for System:
*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
J
Certificate of Completion �` f Date �L21(' x
*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 +r fT,
Environmental Health Section
P. O. Box 665 w► �j J.
Mocksville, NC 27028
1. Application/Permit Requested
By
Mailing Address
Home Phone %may ��a2 ��/^'Ii Business Phone
2. Name on Permit if Different than Above
3. Application/Permit for:
❑ General Evaluation
UG Septic Tank Installation
4. System to Serve: ZHouse ❑ Mobile Home ❑ Place of Public Assembly
❑ Business ❑ Industry
J ❑ ,Other , ❑ Unknown
5. If house, mobile home: Subdivision `y`� �Y �� Section Lot #
❑ Basement/Plumbing
No. of People Z ❑ Basement/No Plumbing
No. of Bedrooms 9 . Z Washing Machine
No. of Bathrooms 2 7 Dishwasher
Dwelling Dimensions 3e5 X GA C;i 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 Showers
7. Type of water supply: IH' Public
8. Property Dimensions
No. of Sinks
No. of Urinals
No. of Water Coolers _
Water Usage Figures _
❑ Private
Sewage Disposal Contractor
9. Do you anticipate additions/expansion of the facility this sytem is intended to serve?
❑ Yes 9y No
❑ Community
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:
This is to certify that the information provided is correct to the best of my knowledge, and I and
incurred from this application.
S- /v - 9.3
DATE SIGNATI
I am responsible for all charges
CONSENT FOR SITE EVA TO BE DONE ON ABOVE DESCRIBED PROPERTY
MUST CHECK ONE: V1 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 ofpavie 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 bsorption sewage treatment
and disposal system.
�m-!23
DATE SIGN U
DCHD (12-90)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
NAME UU�71Ke"/`
ADDRESS
PROPOSED FACIILTY
Water Supply: On -Site Well
DATE EVALUATED
PROPERTY SIZE
LOCATION OF SITE
Community
Public A/
Evaluation By: Auger Boring y___ Pit Cut
FACTORS 1
2
3
4
Landscape position
2-
-S1o
e %
Slope
---
—
—
HORIZON I DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH
Texture group
Consistence
Structure
Mineralogyi
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 RATEI
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 -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