887 Gladstone Road Lot 1DAVIE COUNTY HEALTH DEPARTMENT �-
+'�'� 1 I IMPROVEMENTS PERMIT AND CERTIFICATE` OF COMPLETION
*NOTE: Issued in Compliance With Article II of G.S. Chapter 130a
Sanitary Sewage Systems Permit Number
Name Q2<r / ' k Date —7_�_ — N2 8116
Location
Subdivision Name �2 ,_ I, • ,'r% L- Lot No. l Sec. or Block No. ---Z
—
Lot Size ZZC --- House Mobile Home —__ Business —__ Industry"
No. Bedrooms L _.No. Baths No. in Family _ Public Assembly Other
Garbage Disposal YES ❑ NO p-'
Auto Dish Washer YES NO p Specifications for System:
/ooh <�
Auto Wash Ma^hine 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
ATTENTION: YOUR SEPTIC SYSTEM CONTRACTOR MUST SEE THIS PERMIT/LAYOUT BEFORE INSTALLING THIS
SYSTEM.
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Improvements permit by — ' �7//
*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: 704.634.5988-.22%6O
Final Installation Diagram:
System Installed by
c
/'*
17-1
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Certificate ot,Completion —� _S — 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.
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a
Improvements permit by — ' �7//
*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: 704.634.5988-.22%6O
Final Installation Diagram:
System Installed by
c
/'*
17-1
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Certificate ot,Completion —� _S — 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.
flI I APPLICATION FOR SITE EVALUATIONAMPROVEMENTS PERMIT
Davie County Health Department
8� Environmental Health Section p �7
P. O. Box 665
Mocksville, NC 27028 ✓ ,
\.,l. Application/Permit R luested By
n 1 /
Mailing Address � O �
Home
Phone 2 i�
�1[SViI/ e— N G. a %0 a Business Phone Harr �f
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 ❑ Industry ❑ �tOtth�her /' / ❑ Unknown
5. If house, mobile home: Subdivision-VAAi/7do /Deli/Jf� Section Lot #
❑ Basement/Plumbing
N. of People ❑ Basemeni/No Plumbing
No' 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
No. of Commodes .9 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 �/ tqe, 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:
OM-57�� '000000
Air �s
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
/7
CONSENT FOR SITE EVALUATION TO BE DONE ON AB VE 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 CountyHealth 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.
DCHD•(1193)
DATE
SIGNATURE
r
DAVIE COUNTY HEALTH DEPARTMENT /
Environmental Health Section
Soil1Site Evaluation -
NAME�/11//i✓ DATE EVALUATED
ADDRESS PROPERTY SIZE
PROPOSED FACIILTY LOCATION OF SITE �� >
Water Supply: On -Site Well Community Public
Evaluation By: Auger Boring Pit , % Cut
FACTORS 1
2 3 4
Landscape position 2—,
27 --
Slope %
HORIZON I DEPTH
I e/v
Texture group:
s—L
Consistence
Structure
Mineralogy
HORIZON II DEPTH t
t
Texture group
Consistence
i
Structure
s i
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: ,Ala - `I
LANG -TERM ACCEPTANCE RATE: ti 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
Molst - - -
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 -Nonplastic 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