843 Gladstone Road Lot 7j DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTE: Issued in Compliance With Article 11 of G.S. Chapter 130a
Sanitary/ Sewage Systemss� 1 �� A Permit
Number
Name /,f ��N /6 r %%.CSS// Date /� �8 —9y N2 18 3 2
Subdivision Name _
Lot No. Sec. or Block No.
Lot Size /A -- House — Mobile Home _T Business _-- Industry
No. Bedrooms 1-? No. Baths— — No. in Family _ Public Assembly Other
Garbage Disposal YES ❑ NO p' Specifications for System:
Auto Dish Washer YES NO ❑
Auto Wash Machine YES 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.,
1:00-1:30 P.M. or 4:30.5:00 P.M. on day of completion. Tele Numb@r: 704-634-5985.
Final Installation Diagram:
r
led
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.
U
47
V
Application/Permit
Mailing Address _
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Depj3rtment
Environmental Health Section
P. O. Box 665 • Mp; 4x
Mocksville, NO 27028
2. Name on Permit if Different than Above
3. Application for. 0 General Evaluation ❑ Septic Tank Installation Permit
4. System to Serve: r11
House ❑ Mobile Home ❑ Place of Public Assembly
❑ Business ❑ Industry ❑ �Otthher /' / ❑ Unknown
5. If house, mobile home: Subdivision A/!/Jd� /�i>iivh /S" Section Lot #
❑Basement/Plumbing
No. of People
,No. of Bedrooms
No. of Bathrooms
Dwelling Dimensions
6. If business, Industry, place of public assembly, other: Specify type
No. of People Served
No. of Commodes
L
15�6�
tj
j Public
f n n
No. of Sinks
No. of Urinals
No. of Water Coolers
Water Usage Figures
❑ Private
Sewage Disposal Contractor
❑ Basement/No Plumbing
❑ Washing Machine
❑ Dishwasher
❑ Garbage Disposal
3/expansion of the facility this sytem is intended to serve? Cl Yes ❑ No
❑ Community
-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:
61
A09 fs
This is to certify that the information provided is correct to the best
incurred from this apphc
DATE
and I understand I am responsible for all charges
CONSENT FOR SITE EVALUATION !Q BE DONE Qty 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 W93) - --�
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section]
Soil/Site Evaluation
NAME , DATE EVALUATED
ADDRESS PROPERTY, SIZE 2QX3s�S'
PROPOSED FACIILTY LOCATION OF SITE ��4r'S �IIIo
Water Supply: On -Site Well Community Public /.
Evaluation By: Auger Boring Pit ?/ Cut -
FACTORS
1
2 3 4'
Landscape position
Slope R
Y
HORIZON I DEPTH
Texture groupr
Consistence
Structure
Mineralogy
HORIZON II DEPTH
Texture groupC'
Consistence
/
r
Structure
//
,Y'
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
SITE CLASSIFICATION: //�S EVALUATED BY:
LONG-TERM ACCEPTANCE RATE:_ OTHERS) 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 fine 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 chrome 2 or less
Classification - S(suitable), PS(provisionally suitable), U(unsuitable)
LTAR - Long-term acceptance rate - gal/day/ftz
DCHD (01-901