331 Seaford Road Lot 2DAVIE COUNTY HEALTH DEPARTMENT
r IMKP�ROO�-VEMENTS PERMIT AND CERTIFICATE OF COMPLETION
'NOT
es Liin Cd�pliae With Article II of G.S. Chapter 130a
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Sanitary Sewage SystemsPermitt Number
Name _ '. .;,-- /�//,.v;, /U. r i/ Dat
:�'Y,:/,)/e /. /�_� T� NO U � 1 95
Location �_ .�J% '/ _ , �% �.ar.. ✓ i'
, �, - /i'�% ��[01'>�. 0�{700
Subdivision Name �/`D✓ Lot No. 2— Sec. or Block No. I
Lot Size �»� -- House —ry
Mobile Home — — — — Business --_ Indust
No. Bedrooms c L —.No. Baths —�=L — No. in Family _— Public Assembly Other
Garbage Disposal YES ❑ NO p Specifications for System:
Auto Dish Washer YES NO ❑ /OOD �;0- l 0
Auto Wash Ma-hine YES T NO ❑ 3DII X k��
Type Water Supply _ GIJ�CP _-----•---
*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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for
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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:
M
System Installed by
I��r
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.
�y j! APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PER LS C V
/ - Davie County Health Department
Environmental Health Section -7
P. O. Box 665
Mocksville, NC 27028
a,
1. Application/Permit Requested By CIQ✓1165 V 0 yJctrr/Wn/e &Air4r-
MailingAddress.131 0-Af/LV,`Pr.i boive- Home Phone
A42[ KEvY t P. A4C, AMP 8 Business Phone 9i40 %/8-2- Uy
2. Name on Permit if Different than Above
3. Application for: General Evaluation Septic Tank Installation Permit
4. System to Serve: V Rouse ❑ Mobile Home ❑ Place of Public Assembly
❑ Business ❑ Industry ❑ Other ❑ Unknown
5. If house, mobile home: Subdivision n f&4 C4.«%A &gw-IX Section Lot #
n (� � / ❑ Basement/Plumbing
No. of People �� c� u3'ctY5 �1i�lr L �i ✓2 I1 Bo? g ie �� i"p �❑ Basement/No Plumbing
No. of Bedrooms -:5 ^Washing Machine
No. of Bathrooms 3 �"ishwasher
Dwelling Dimensions �a r� X ,m SW ❑ 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
No. of Sinks
No. of Urinals
No. of Water Coolers
Water Usage Figures
7. Type of water supply: ❑ Public 3,49034ceav N -Private
8. Property Dimensions pf Emir- SirY2S Sewage Disposal Contractor
9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? J Yes Z`No
If yes, what type?
❑ 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:
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4SPo�or�/io�cd�-
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Cor,ver C>Sea o 400 b dVp ` R`�xd or B4So"nvw� I {,Al
This is to certify that the information provided is correct to the best of my knowledge, and I understand I am responsible for all charges
incurred from this application. ,"2i ,V%210
/ DATELI, SIGNATURE
CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY
MUST CHECK ONE: X 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.
DCHD (1197)
DATE SIGNATURE
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
NAME djYi DATE EVALUATED i
ADDRESS PROPERTY SIZE .
`i
PROPOSED FACIH.TY /i/Oct� � - LOCATION OF SITE
i
Water Supply:
Evaluation By:
On -Site Well i/ _ Community" - Public- -" -
Auger Boring Pit Cut -
FACTORS
1
2
3 4
Landscape position
[
—
Slope r $
11
02
HORIZON I DEPTH
Texture groupL
L
CL
Consistence
Structure
Mineralogy
HORIZON II DEPTH
Texture group
C
Consistence
,
Structure
t
Mineralogyj,-
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: .. .. .. .
DCHD(01-901
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- -
" VlV 1lYl\Yli"
Moist -
VFR-Very friable FR -Friable FI-FirmVFI-Very firm
Wet
NS -Non sticky SS Slightly sticky S -Sticky VS -Ver
NP -Non plastic SP -Slightly plastic .P -Plastic' VP-{
Structure
SC -Single grain M -Massive CR -Crumb GR -Granular
SBK-Subangular blocky PL -Platy PR -Prismatic
ABK-Angular blocky
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/ftz