859 Gladstone Road Lot 5exp r/P
DAVIE COUNTYV'HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
-*-NOTE: Issued in Compliance With' Article I I of G.S. Chapter 130a
Sanitary Sewage /Sy/stems o Permit Number
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Name 19iS ep,p Date g �/ N27736
41c, �%i6r/i�6 !� l� ®i✓ �`Y /L9T�r�is�,✓ ('�_
Subdivision Name Lot No. Sec. or Block No.
Lot Size i C House Mobile Home _ Business Industry
No. Bedrooms N-7 No. Baths —c:Z— No. in Family — Public Assembly Other
Garbage Disposal YES ❑ NO 0-0' Specifications for System:
Auto Dish Washer. YES p NO ❑ /�p��./Y�
Auto Wash Ma;hine YES 41 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..
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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. Telephone Number: 704-634-5985.
Final Installation Diagram:
System Installed by I = � Z)_% -°r
e
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Certificate of Completion --- SZ- Rj 4 Date 11 -((A -9q
'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 qiven period of time.
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
S i1/451'te Evaluation
// 0
NAME
ADDRESS
PROPOSED FACIILTY
DATE EVALUATED
PROPERTY SIZE %ape
LOCATION OF SITE
Water Supply: On -Site Well - Community Public a� -
Evaluation By: Auger Boring Pit Cut
FACTORS
1 2 3 4
Landscape position
Slope
HORIZON I DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH
Texture group
Consistence
Structure
C
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: EVALUATED BY:
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 -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:i, Mixed -
Notes
Horizon depth - In inches
Depth of fill - In inches
Restrictive horizon - Thickness and inches from land surface
Saprolite - S(suilable), 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
'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
Incurred from this applic
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
DCMO (103)
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APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
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Davie County Health Department
:1
1
Environmental Health Section
Mocksviile, NC27028
1 Application/ Permit Ri nested B
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Mailing Address D
1
Home Phone
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N cam, �rtp - ff`'., ` Business Phoneme 0�
2. Name on Permit if'Different than Above
3. Application for: ❑
General Evaluation ❑ Septic Tank Installation Permit
4. System to Serve: House "
❑ Mobile Home ❑ Place of Public Assembly
❑ Business. 0 Industry
// ❑ ��Other / ❑ Unknown
5. If house, mobile home: Subdivision ,�dA,07
/710 Section Lot #
❑ Basement/Plumbing
�,. No. of People
❑ Basemenf/No Plumbing
tNo. of Bedrooms
❑ Washing Machine
No. of Bathrooms'
❑ Dishwasher
Dwelling Dimensions
❑ Garbage Disposal
6. If business, industry, place of public assembly, other; Specify type
No. of,People Served
No. of Sinks
of Commodes
No.. of Urinals
No. of Lavatories
No, of Water Coolers
No. of Showers
Water Usage Figures
7. Type of water supply: Public
❑ Private ❑ Community"
)
8. Property Dimensions,/�!{ C
Sewage Disposal Contractor
9. Do you anticipate additions/expansion of the
facility this sytem is Intended to serve? ❑ Yes ❑ No
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
Incurred from this applic
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
DCMO (103)