924 Mr Henry Road Lot 9OPERATION PERMITF7::
SYSTEM IN�LEp�:
.. - .�
*,*THE ISSUANCE OFT S OPERATION ERMTT SHALL INDICATE THAT THE,SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE
ITH AR 1CL.E.11 OF G. A, SECTION .1900 "SEWAGE TREATMENT AND DISPOSAL SYSTEMS'; BUT SHALL IN NO WAY. BE TAKEN AS A
GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY OWEN PERIOD OF TIME
DCHD 0516 (Revised)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
PO Box 848/210 Hospital Street
Mocksville, NC 27028
Phone: (336)751-8760
ON-SITE WASTEWATER CERTIFICATION FOR
(Check One) REPLACEMENT ❑ REMODELING ❑
Name: Jw MC1 W ee Phone Number:0
Mailing Address: Mr.'Ae� ry Kd .
YV1hc-�5,/�IIG ''
Detailed Directions To Site: e j e !j lv� r �
3 M'% I e c. %-F t"'. Frt e_ Yn u. We -V4 - 61e
Property
Please Fill In The Following Information About The Existing Dwelling:
Name System Installed Under: C 1 ; f4 v-" Type Of
Date System Installed(Month/Day/Year): 4 3 q,4 Number Of Bedrooms-.-a—
Is
edrooms:Is The Dwelling Currently Vacant? Yes p' No ❑ If Yes, For How Long?
Any Known Problems? Yes ❑ No l3 If Yes, Explain
Please Fill In The Following Information About The New Dwelling:
Type Of Dwelling: 1inAle w fA a Number Of Bedrooms: 3 Number
Requested
For Environmental Health Office Use Only
Approved ❑ Disapproved ❑
29
Environmental Health
iCTION ❑
11Z5 (Home;
"123.:& (Work;
qte. s' -a-6o�`i
(lfll)O MYb iG U
Of People: 2
;7-
For
2
"The signing of this form by the Environmental Health Staff is in no way intended, nor shoul4be taken as a
guarantee(extendec�. limited) that the on-site wastewater system will function properly for y given period/of time.
Payment- Cash ❑ Check ❑ Money Order ❑ # —Amount- $ iZ �
Date:
Paid By- Received By:
Account #: �� 2 S Invoice #:
s
DAVIE COUNTY HEALTH DEPARTMENT I
-
1, IMPROVEMENTS PERMIT'i;AND, CERTIFICATE. OF COMPLETION _
tNA' *NOTE: Issued in Compliance With Article I I of.G.S. Chapter 130a s j
Sew a yst msS/c?y�9 rm
a i P,e it Number
•
1tName, /rir:rp./�JJ.•Date ...._, ... 4„3 0 7191
� ✓ y� / i� _
Loca
Subdivision Name Lo No. Sec. of lock No.,
"Lot Size.- House' Mobile Home Business Speculation
1
-'No.Bedrooms _ :No: Baths �No � m Family t — L
a
_Garbage Disposal YES,_❑ NO,{❑��. Spe lific tions fyo
,Auto Dish Washer',. :.YES •[�/NO
4Auto Wash'Ma 'Ma- •.•YES• ❑ NO
Type Water Supply... /i
'This permd Void if sewage system described below is not,installed within 5 years from d te of Issue
;;This permit is subject to revocation if site plans or the intended use change ”'
tf i... ,. i
i
'.j7 4 j r Ir I d 1 - - .-.
No
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1
1
,
3
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.' p l J I i 1 1 � .. ♦.r
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t. d:.a...'7 Ti -
Ila
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Improvets permitby
/:, !. m,aenul
;'Contact a representative of the Davie County Health Department for final inspectionof this system between 8:307
9:30 A.M. or 1:00-,1:30 P.M. on;day;,of,com, pletidn,,,Tglep pne„Number 704-634-5985{, J,
? ”. - - i,r; ...'JAu �. :,Y..) IC.a. I,y In?/ r;i .. .•-+�v�c.,or� J_lJ'Ai`^' .
Final Installatwn Diagram. �.r n System Install
Hrj
7 ,1
. &
P6 s.a:P tp
.•:..n,S, ''illi ,.\ : '1)i!I 'ul l:ei'.
--. [rs'I'•tls of i`tl� , ',Ir+ „� -
i\':aYt l,,i'IP' .; J•�.,! A.. .'1 ta(.(tin dl 1 �-_ ,
�qtl �lr. r'35, Ia r r I ro! I`r.! 6f i:l t. .y. fr<: o ntiy. o•..r fcurn 1,11r} f$ t.i':,Ni ..t hrr .,
C i ;ct(161, 1, 1 ,z >'.7,- ! �+ , \ rv;g•.rp _ -ted � 1,.i.,.
:Certdic t$ of ompl tion a�'�w Date 1
'The signing of this certificate shall indicate that tfie system escrib d wove. has been installed in compliance with
�>v_fui the standards set forth in the above regulation, but shall in NO way be taken as a guarantee that thesystem will function
--.I-f--.-.:1•. 1n. n.,,.......,- ..-.:..d of 4;
'OXO
DAVIE COUNTY HEALTH DEPARTMENT
rlr,, IMPROVEMENTS PERMIT AND CERTIFICATE .OF COMPLETION _J
'NOTE: Issued in Compliance With Article 11 of G.S. Chapter 130a
, ta.. Sewage Systems Permit �mb�er
Name /. f %pn at. �Xll. ilrs.✓ rJi�%�sYr�l/%%u.�� .Date 7s� y/Ly� NO
?�'i. � /. f'/ %d Wil/ %✓'� %/. ; a— /✓� /%��/�!'iv j 11i✓ �i� In%` � •
Locatlorr_
Subdivision Name o� Lot No. / Sec. or Block No.
!IC
Lot Size House / Mobile Home Business Speculation
No. Bedrooms No. Baths No. in Family _
Garbage Disposal YES ❑ NO Spe ific tions,,fo Syste y + ��
Auto Dish Washer YES C)/NO ❑ %Do.�s'. G
Auto Wash Ma shine YES ❑]NOo❑
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 _— //i/ .
*Contact
'Contact a representative of the Davie County Health Department for final inspection of this system between 8:30-
9:30 A.M. or 1:00-1:30 P.M. on day of completion. Telephone Number 704-634-5985.
Final Installation Diagram: 3 System Installed byp��o�
d
Certificate of Compl tion_ Date
"The signing of this certificate shall indicate that the system Idescrib d 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 anv riven Deriod of time.
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
NAME DATE EVALUATED
ADDRESS PROPERTY SIZE S/�G
PROPOSED FACIELTY LOCATION OF SITE /%% rl�l vr,./
i
Water Supply:
Evaluation By:
On -Site Well ✓
-Auger Boring
Community
- .Pit
Public - -:
Cut
1 L L
Slope %
FACTORS1
2 3 1 4
Landscape position
1 L L
Slope %
J*_HORIZON
I DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH
O "
Q "
Texture group
Consistence
Structure.
Mineralogy
HORIZON III DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture rou
Consistence
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE -W
HORIZON
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE
SITE CLASSIFICATION: G//. `Y�i� /% EVALUATED BY: �`� &
LONG-TERM ACCEPTANCE RA E: �� OTHER(S) PRESENT:
REMARKS:. [rig
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 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, 2:1, 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
S
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section _
P. O. Box 665
Mocksville, NC 27028
1. Application/Permit Requested By l it xf LO ( I YLfG7 j, v
Mailing Address /Qf % /30X �e maG�sV/ /(e /06 �7d2
Home Phone 1�.3y- '-37'%sBusiness Phone �'Jc�- �ySS
2. Name on Permit if Different than Above
3. Application/Permit for: ❑ General Evaluation X, Septic Tank Installation
4. System to Serve: ❑ House 2'9-obile Home ❑ Place of Public Assembly
❑ Business ❑ Industry ❑ Other ❑ Unknown
5. If house, mobile home: Subdivision �(/7`� /�J�✓Lr .6e of S" Section • Lot #.
❑ Basement/Plumbing
No. of People C>11' ❑ Basement/No Plumbing
No. of Bedrooms o2 111'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 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 XPrivate
8. Property Dimensions c-5. K t 5 Sewage Disposal Contractor
9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes
If yes, what type?
❑ Community
'NOTE: Improvements Permits shall be valid for a period of 5 years from dat issued. Improvements Permits are subject to
revocation, if site plans or the intended use change. Effective October 1, 1989.
Directions to Property:
Pe- /- nrLj er( Lo+ 9 /Dt)SS 4)42M P/Otx�C-
/�e�`v/e-
Sem` S,eohc
3
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
J�this application. r �3
D�E SIGNATURE
CONSENT FOR SITE EVALUATION TO BE DONE ON 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 MUS ST 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 (12-90)