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864 Mr Henry Road Lot 4Z14'"ySC6 DAVIE COUNTY HEALTH DEPARTMENT -�I I OVEMENT$-PER T A D CERTIFICATE OF COMPLETION •NOTE: Iss eiliri Cohip�ance With Arty?e{of G. � 1 Sanitary Sewage Syste s - ,[�,-r Permit Number " Name 42: Date— ` 4�' g S N2 8052 Location/ Lol��i t O l/���'�--/� /��V l'i[fiv �r�/�!/� _ Subdivision Name SOu�� �/w� f77vr» Lot No. _r�_ Sec. or Block No. Lot Size _—_ House.— Mobile Home — — — — Business —_— Industry No. Bedrooms —.No. Baths No. in Family- Public Assembly Other Garbage Disposal Auto Dish Washer YES ❑ NO p� YES NO Specifications for System• Auto Wash Ma-hine YES NO ❑ �% Qu��sH. Ute( Type Water Supply r 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.. /00 / Or" / 0 Improvements permit by —f—" - *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 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. 1. Application/Permit Mailing Address APPLICATION FOR SITE EVALUATION/IMPROVEMENTS Davie County Health Department Environmental Health Section P. O. Box 665 Mocksville, NC 27028 2. Name on Permit if Different than Above 3. Application for: 0 General Evaluation 4. System to Serve: ❑ House ❑ Business ❑ Industry 5. If house, mobile home: Subdivision No. of Peopley No. of Bedrooms '__J No. of Bathrooms Dwelling Dimensions o�n X 7y Business Phone e,3y %6 /. � , Tank Installation Permit W Mobile Home ❑ Place of Public Assembly ❑ Other ❑ Unknown 6. If business, industry, place of public assembly, other: Specify type No. of People Served No. of Commodes No, of Lavatories _ No. of Sinks No. of Urinals No. of Water Coolers No. of Showers Water Usage Figures. 7. Type of water supply: ❑ Public Private 8. Property Dimensions A/O i _eelldy Sewage Disposal Contractor 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? If yes, what type? Section Lot # ❑ Yes ❑ Basement/Plumbing ❑ Basement/No Plumbing 24ashing Machine Dishwasher ❑ Garbage Disposal M ❑ 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: NZ.- Z.- s�• '�� S�'� r,© '" � � on --ra�.t,�, R� (�'.o --}d �'N7 -+; YAf- RSA . �� ►7��1� Ae-r�ss This is to certify that the information provided is correct to the best of my incurred from this application. DAT w: it � � /--/ w/ /11--ZIAP and I understand I am responsible for all charges CONSENT FOR SITE EVALUATION TQ BE DONE ON ABOVE DESCRIBED PROPERTY MUST CHECK ONE: ❑ 1. 1 OWN the property. [W 2. 1 DO NOT OWN the property. If you checked Box #2, the rest of this form MMI, T be completed by the owner or a person authorized by the owner: I hereby give consent to the authorized representative of the Dayj*e County alth p ent to enter upon above des� fJib property located in Davie County and owned by tvt t AKDsrT Li? e rAh cJ to conduct all testing procedures as necessary to determine said site's suitability fo roun absorption sewage treatment and disposal system. d� � TE 9 SIGN RE DCHD (Vre3) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation NAME �� DATE EVALUATED ADDRESS PROPERTY SIZE PROPOSED FACIILTY TION OF SITE ff/✓ N4YH . N Water Supply: On -Site Well 2 3 4 -' Community - '- Public Evaluation By: AugerBoring - Pit - - Cut - FACTORS 1 2 3 4 Landscape position L� L 2_ Sloe $ 2 HORIZON I DEPTH Texture group L L Consistence Structure Mineralogy HORIZON II DEPTH IT4 77 Texture group Consistence l Structure i y Mineralogy HORIZON III DEPTH 7- 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:. '(n /li� EVALUATED BY: LONG-TERM ACCEPTANCE RATE: OTHER(S) PRESENT: REMARKS: t'ilG i✓ y�?li I 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 :lay loam- SIL -Silty loam CL -Clay loam SCL-Sandy clay loam SC -Sandy clay - SIC -Silty clay C -Clay - - CONSISTENCE - Moist - .. VFR-V,!ry friable FR -Friable, FI -Finn VFI-Very firm EFI-Extremely fine 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 CR -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/f(2 DCHD(01-901