233 Riddle Circle Lot 23DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
NOTE. Issued in Compliance With
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nitarySewage�ystems�-
Unr,'✓c iP�efrmit/�Number
Name 7/ .y/ -i?
Date NO 7219
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Location 1/P
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Subdivision Name `I` /F Lot No. Sec. or Block No.
7
Lot Size �ifC House Mobile Home —/'�' Business _— Speculation
No. Bedrooms No. Baths o2 No. in Family
r,
Garbage Disposal YES ❑ NO (�j
E]Sp,?cifications,.foSystem:
Auto Dish Washer' YES NO jUGG'� .�
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.
Improvements permit by
'Contact a representative of the Davie County Health Departmgnt 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: - System Installed by v
m
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Certificate of Completion Date 1-$- 93
'The signing of this certificate shall indicate that the system describe above has been installed in compliance with
the standards set forth in the above regulation, but shall in NO way betaken as a guarantee that the system will function
satisfactorily for any given period of time.
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 �� I —tw r
Mailing Address S% c/ '9 '41
Home Phone a usiness Phone
2. Name on Permit if Different than Above v5 1
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3. Application/Permit for: ❑ General Evaluation L9 Septic Tank Installation
4. System to Serve: ❑ House Er Mobile Home ❑ Place of Public Assembly
❑ Business ❑ Industry ❑ Other ❑ Unknown
5. If house, mobile home: Subdivision --5¢e r, . 3 J+ I -e- Section - Lot # 3
No. of People oZ
No. of Bedrooms
No. of Bathrooms
Dwelling Dimensions
6. If business, Industry, place of public assembly, other: Specify type
No. of People Served No. of Sinks _
No. 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
8. Property Dimensions Sewage Disposal Contractor
9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes
If yes, what type?
❑ Basement/Plumbing
❑ Basement/No Plumbing
❑ Washing Machine
❑ Dishwasher
❑ Garbage Disposal
❑ 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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(�Jo bcNcr�� ��myya�� mev�" � s�� ar• ^�r«�-.r.-2 roocQ. / Q/to-zts?CD Sn /�
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.
ct L I / l'1
DATE 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 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
DCHD (12-90)
DAVIE COUNTY HEALTH DEPARTMENT - -.
Environmental Health Section
n Soil/Site Evaluation
NAME I G��- 'DATE EVALUATED
ADDRESS PROPERTY SIZE
PROPOSED FACIILTY q LOCATION OF SITE ois
Water Supply:'
On -Site Well
- - ;Community
:Public -� -
Evaluation By:
Auger Boring
.Pit
Cut
FACTORS 1
2
3
4
Landscape position G
2
L
G
Sloe Z
HORIZON I DEPTH --
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH
Texture group
G
G
Consistence
Structure
S
r k
f l
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
r
L
SITE CLASSIFICATION: S' EVALUATED BY:�
LONG-TERM ACCEPTANCE RATE: OTHER(S) PRESENT:
,REMARKS:
LEGEND
Landscape Position - - -
R -Ridge S -Shoulder L -Linear slope FS-Footslope -- 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(01-90)
DAVIE COUNTY HEALTH DEPARTMENT �i�23
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name G 6�5�- Date—
Address
ate Address Lot Size
FAr:TnP.Q ARFA 1 ARFA 9 ARFA.q ARFA d
Topography/ Landscape Position
-ZfT:)
S
S
S
PS
PS
PS
PS
U
U
U
U
!) Soil Texture (12-36 in.) Sandy,
<�
S
S
S
Loamy, Clayey, (note 2:1 Clay)
PS
PS
PS
PS
U
U
U
U
I) Soil Structure (12-36 in.)
�
S
S
S
Clayey Soils
PS
PS
PS
PS
U
U
U
U
q Soil Depth (inches)
�
S
S
S
PS
PS
PS
PS
U
U
U
U
i) Soil Drainage: Internal
S
S
S
PS
PS
PS
PS
U
U
U
U
External
S
S
S
PS
PS
PS
PS
U
U
U
U
i) Restrictive Horizons
Available Space
S
j
S
PS
S
PS
S
PS
U
U
U
U
3) Other (Specify)
S
S
S
S
PS
PS
PS
PS
U
U
U
U
!) Site Classification
U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable
Recommendations /Comments:
Described by _
SITE DIAGRAM
z,�3.Y1
DCHD (6-82)
Title
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137.1/7 Lni*k 23
768' At-
X
/23.7s"
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Date 8.2 "kr