360 Buck Seaford Road- r DAVIE COUNTY HEALTH DEPARTMENT
A� IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTE: Issued in Compliance With Article II of G.S. Chapter 130a
_Sanitary Sewage Systems _
Nameti: `.� �!J ! r� >=. Date
Location > . c, �� t"` .\
V
Subdivision Name \ \ . Lot No. -
j'J'
Permit Number
No .�
—
Sec. or Block No.
Lot Size 1`—I House Mobile Home _ Business _— Speculation
No. Bedrooms No. Baths No. in Family —
Garbage Disposal YES ❑ NO . Specifications for System:
Auto Dish Washer YES ff NO E]`' - � �c�:` , v �; ^ -
Auto Wash Machine YES [X 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 plansjor"the intended use change.
z
i
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
Certificate of Completion __t'F r Gz / T 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 cSID
Mockoville, NC 27028 v
1 rl-
1. Application/Permit Requested By �)v
Mailing Address ��� - S / `7 IV- • 2
Home Phone 10J't'- 12=23 Business Phone �� �: Yotc,-{(eS
/U o
2. Name on Permit if Different than Above //�� I
3. Property Owner if Different than Above 1�J0. ke V GS1a-�S
4. Application/Permit For: &.-Q-6-neral Evaluation a-6-1vank Installation
5. System to Serve: louse u Mobile Home 0 Business
L Industry u Other Unknown
6. If house, mobile home: Subdivision Sec. �/ Lots
(7" fv
No. of People 5— Dwelling Dimensions �r7 V
No. of Bedrooms _ 3--Basement/Plumbing
No. of Bathrooms Basement/No Plumbing
S,il'ashing Machine Dishwasher 0 Garbage Disposai
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
8.
Type of water supply:
C J<jblic
C] Private [) Community
9.
Property Dimensions
Z®_O 11V U
X 3bo X 1-1-L/ •8/�J"��R s
10. Sewage Disposal Contractor
11. Do you anticipate additions/expa`nsions of the facility this system is
intended to serve? C] Yes V"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 tnat the information provided is correct to trie
best of my knowledge, and I understand I am responsible for all
charges incurred from this appl ca on.
'-7- s- % L), �
Date Signature
Directions to Property:
G
p�
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DCHD (10-89) ad! � a a,` �. r C
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Ca
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, P. O. Box 665, Mocksville, N.C. 27028
Davie County Health Department
Environmental Health Section
Site Evaluation Consent Form
LOCATION OF PROPERTY: DATE RECEIVED
d(office use only)
(fcQ•
yes no 1. 1 am the owner of the above described property.
yes no 2. 1 am not the owner of the above described property, however, I certify that I
have consent from %ear-�/-/- 3'�/ , owner to obtain a
owners name
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.
DATE
SIGNATURE
4. 1 hereby authorize the Davie County Health Department to release site
evaluation results from the above described property to the following:
DATE
DCHD (11 /84)
— Owner only
— Owners designated representative
— Anyone requesting results
— Only those listed below
SIGNATURE
DAVIE COUNTY HEALTH DEPARTMENT
• Environmental Health Section
Soil/Site Evaluation
NAME _ - ��- DATE EVALUATED
ADDRESS S Qyc" si PROPERTY SIZE O� o q S Ord
PROPOSED FACIILTY \\ o J S a LOCATION OF SITE
Water Supply: On -Site Well Community
Evaluation By:�_F1- Auger Boring ✓ Pit
Public
Cut
FACTORS
1
2
3
4
Landscape position
f'
S
Sloe 7.�-
HORIZON I DEPTH
`
Texture group
C" Cs
c
S c
S c
Consistence
r F r
ff
F R
Structure
G
jZ
F 6
Mineralogy;
1
�•
1
HORIZON II DEPTH
41a'
•
U
'-I 2
L y c
Texture group
5 CC -
Consistence
Consistence
�
F T
E F�Z
g
f R
Structure
C
G
Mineralogy
HORIZON III DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
S
S
SS
5-5
RESTRICTIVE HORIZON'-
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE
SITE CLASSIFICATION:
LONG-TERM ACCEPTANCE RATE:
REMARKS:
DCHD (01-901
EVALUATED BY:
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
'r- t. -
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 -Finn 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