114 Oak Tree Drive Lots 146 & 147t r _ � '� - - -- -. --- - - �--••-�.- ..T•snw-r---.,�..- :-`„�,�cyy�'a'.w^r'S-'a"r�•--r lam+ --w- •�1
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• j' DAVIE COUNTY HEALTH DEPARTMENT
r. 4 QI
I IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*14OTE: Issued in Compliance With Articled of G.S. Chapter 130a
_ ,_.Sanitary Sewage Systems ! Permit Number
Name`"��`� 1!1..x: \a \'�= _Date �.J. NQ 8 162
t.
Location :� ,ar ��\.c�_
Subdivision Name' Lot No. Sec. or Block No.
Lot Side "A" _ �' Q House Mobile Home Business Indust
�---� ry
U
No. Bedrooms __.!No. Baths _-- No. in Family _ Public Assembly Other
Garbage ,Disposal YES C NO p� Specifications for System:
Auto Dish Washer YES. NO:, C ! d 4
a ,
Auto Wash Ma hike YES NO,, ❑ .� ►
Type Water Supply _ i;Q c -- :.J j`:, J\A_
This permit Void if sewage system described below isnot installed within.5 years from date of issue.
This permit is subject. to revocation if site plan's or the intended use cha'nge',
ATTENTION: YOUR SEPTIC SYSTEM CONTRACTOR MUST SEE THIS PERMIT/LAYOUT BEFORE INSTALLING THIS
SYSTEM
I r
�• air , ' t
Improvements permit 6y
*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
4
C Cl
• � i � gig. �� �� �� t'
+J Certificate of Completion _ Date
The signing of this certificate shall indicate that the system described above has. been installed -in compliance with
.1 the standards set forth in the above regulation, but shall in Noway betaken as a,guarantee that the;system will function
satisfactorily for any given period of time,. ;
1. Application/Perp
Mailing Address
2. Name on Permit if Different than Above
3. Application for: ❑ General Evaluation
4. System to Serve: ❑ House
Septic Tank Installation Permit
Mobile Home ❑ Place of Public Assembly
❑ Business ❑ Industry / El Other ❑ Unknown
5. If house, mobile home: Subdivision l.r 1!� V- V fA•-Section Lot # cY- /4/7
No. of People
No. of Bedrooms
No. of Bathrooms I
Dwelling Dimensions 140D - % 0n ) o
6. If business, industry, place of public assembly, other: Specify type
No. of People Served
No. of Commodes
No. of Lavatories
No. of Showers /
7. Type of water supply: Q Public
8. Property Dimensions
No. of Sinks
No. of Urinals
No. of Water Coolers _
Water Usage Figures _
❑ Private
Sewage Disposal Contractor
❑ Basement/Plumbing
❑ Basement/No Plumbing
ET -Washing Machine
C'Dishwasher
❑ Garbage Disposal
9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? L'Ves ❑ 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:
6 4 bL�� �, -)O—� " A44-1 Rei :R �)d '&� a",
✓�A�
L7R
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.
2- /g -7S-
DATE SIGNATURE
CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY
MUST CHECK ONE: ❑ 1. 1 OWN the property. Er2. I 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 the 9avie Courity Health Department to enter upon above described
property located in Davie County and owned by
to conduct all testing procedures as necessary to detlnine aid site's s itability for a ground absorption sewage treatment
and disposal system.
Q 11
DATE SIGNA RE
DCHD (1/93)
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• DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation q �r
NAME'P't+n`zS �- O �y `�� DATE EVALUATED :)--s ' 1\7
ADDRESS S Prr Q PROPERTY SIZE J !fS
PROPOSED FACIILTY \'IN` LOCATION OF SITE (D h�\ >v 1lk: fiPMCS
Water Supply: On -Site Well _ Community Public t✓
Evaluation By CZ � Auger Boring Pit Cut
FACTORS
1
2
3
4
Landscape position
-S
s
Sloe X
HORIZON I DEPTH
n
��
Texture group
Consistence
t
Structure
C
Mineralogy1
%!
HORIZON II DEPTH''
LA
Texture group
C
C
Consistence
"
Structure
K
D
Mineralogy
HORIZON III DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
S
S -s
S
SS
RESTRICTIVE HORIZON
--
SAPROLITE
CLASSIFICATION
NIS
LONG-TERM ACCEPTANCE RATE
SITE CLASSIFICATION: EVALUATED BY:
LONG -TER
REMARKS:
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- V12 -y 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
3C --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
Ilorizon 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