246 Deadmon Road Lot 3DAVIE COUNTY HEALTH DEPARTMENT
I
(IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
'NOTE Issued in Compliance With Article II of G.S. Chapter 130a
2 ° ✓X0
Sanitary Sewage Systems Permit Number,
Name /c-'�Zw1"11AL_dr/ Date f'/l1;- . No 7926
Location Otl 4-, —
�� ,�� i i
Subdivision Name _ - �. Lot No. Sec. or Block No.
Lot Size House _ Mobile Home
No. Bedrooms ---5--.No. Baths —2 _ No. in Family:!
Garba a Dis osaI YES NO
Business _—_ Industry
Public Assembly Other
g p ❑ Specifications for System:
Auto Dish Washer YES NO ❑ /`� ,,�jY /��r,
Auto Wash Ma^hine YES NO ❑ mop
Type Water Supply
r Ji:ci;
'This permit Void if sewage system described below is, not installed within 5 years from date of issue. �„ t`\
This permit is subject to revocation if site plans or the intended use change
ATTENTION: YOUR SEPTIC SYSTEM CONTRACTOR MUST SEE THIS PEf MIT/LAYOUT BEFORE INSTALLING THIS 9,_
SYSTEM.
*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: 704.634.5985.7 %6O
I
Final Installation Diagram: System Installed by
Ev
F
Nous
Certificate of Completion = ° asz Date S -'z�g _
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.
° APPLICATION FOR SITE EVALUATION
Davie County Health De
Environmental Health
P. O. Box 665
Mocksville, NC 27
1. Application/Permit Requested By.
Mailing Address
1 01995
Home Phone Y& —
Business Phone QW -4w-
2. Name on Permit if Different than Above '_&-
3. Application for:
0 General Evaluation ❑ Septic Tank Installation Permit
4. System to Serve:
House
❑ Mobile Home
❑ Place of Public Assembly
❑ Business
❑ Industry (� ❑ 9/JDther
rat,
❑ Unknown
5. If house, mobile home:
Subdivision
Section Lot #
❑ Basement/Plumbing
No. of People
❑ Basement/No Plumbing
No. of Bedrooms
3
A Washing Machine
No. of Bathrooms
2
J,VDishwasher
Dwelling Dimensions
.6
PGarbage Disposal
6. If business, industry, place
of public assembly, other:
Specify type
No. of People Served
No. of Sinks
No. of Commodes
No. I f Urinals
I
No. of Lavatories
No. f Water Coolers
No. of Showers W
7. Type of water supply: Public
8. Property Dimensions M0 //'_:w Sewage
9. Do you anticipate additions/expansion of the facility this sytem is intent
If yes, what type?
Usage Figures
Private ^^ //❑ Community
posal Contractor c 1h/F_
to serve? ❑ Yes * No
"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:
601 soz'-M /0"-/
This is to certify that the information provided is correct to the best of my knowledge, an I understand I am responsible for all charges
incurred from this application. e
DATE SIGNATURE
CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY
MUST CHECK ONE: Ii 1• I 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 i
to conduct all testing procedures as necessary to determine said site'si suitability for a ground absorption sewage treatment
and disposal syste .
DATE SIGNATURE
DCHD'(1197)
r ti:M` APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department I
Environmental Health Section RECQ 11 II 1G
P. O. Box 665
Mocksville, NO 27028 NUV 2 8 OJIf
1 A /I D ---------------
pplication/Permit Requested By / C P
/ r
Mailing Address %> s • fI%a, ✓ rlegc7 Home Phone_
l� tJGK3�/��r Business Phone 7D 4�/�`�- 7-2-22-
2.
22Z
2. Name on Permit If Different than Above
3. Application for:
4. System to Serve:
Evaluation ❑ Septic Tank Installation Permit
❑ Mobile Home ❑ Place of Public Assembly
❑ Business ❑ Industry ❑ Other ❑ Unknown
5. If house, mobile home:'Subdivision ,SOU4 a (Ll "ga Section _T__ Lot # 3
No. of People ✓,�Z
No. of Bedrooms
No. of Bathrooms
Dwelling Dimensions A234ar• 796
6: If business, Industry, place of public assembly, other: Specify type
No. of People Served ,cl/,A
No. of Commodes
No. of Sinks
No. of Urinals
No. of Lavatories No. of Water Coolers
❑ Basement/Plumbing
❑ Basement/No Plumbing
WV ashing Machine
Dishwasher .
❑ Garbage Disposal
No. of Showers Water Usage Figures
7. Type of water supply: Public J ❑. Private ❑ Community
8. Property Dimensions Sewage Disposal Contractor
9. Do you anticipate additions/expanslon of the facility this Warn is intended to serve? ❑ Yes No
If yes, what type?
[_:OTE-. 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,
This is to certify that the information provided is correct to the best of
incurred from this appPitatioq.
ill4,1 1 �l
AT
I am responsible for all charges
NET 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 SIGNATURE
DCHD (1/93)
t^
1
2 3 4
Landscape position
' DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Sloe S
Soil/,Site
Evaluation
HORIZON I DEPTH
NAME 1¢
r) W 1 C R F ay d
DATE EVALUATED
L
p
q
ADDRESS S 1P�yi\PROPERTY
SIZE
i ool �!. 3 00'
PROPOSED FACIILTY t S O U Sq.
LOCATION OF SITE
Mineralogy
HORIZON II DEPTH
Water Supply:, On -Site Well Community Public
,Evaluation By: Auger Boring - Pit 1✓ - Cut
FACTORS
1
2 3 4
Landscape position
Sloe S
O •b
d $
HORIZON I DEPTH
Texture groupL
L
Consistence
L
Structure
(
L
Mineralogy
HORIZON II DEPTH
3 L�`
Texture group
Consistence
Z
t
Structure
MineralogyI
HORIZON III DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
S S
SS
RESTRICTIVE HORIZON
—
SAPROLITE
CLASSIFICATION
S
S
LONG-TERM ACCEPTANCE RATE
SITE CLASSIFICATION:
LONG-TERM ACCEPTANCE RATE: L4
REMARKS: � - � - I ' I
EVALUATED BY:
OTHER(S) PRESENT:0.
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 -Finn VFI-Very fine 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 plastica
Structure
SO -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