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3949 Hwy 64W Lot 3-4• � ..r- .�q. •.� •,r-� s r� �.....w- _�-- �..�;,�,.pw�ry�r-r.p,,�r-..r.a•vr �►R......-. w -7c0 �_'z"� "�'ii,�i'F�,.'-Pv _ :"•rr-V��'FiMT'T �'�'R*""1.- ,-•--•,� R _,q�.... . fa., �c o DAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION * NOTE:Issued in Compliance With Article I I of G.S. Chapter 130a nitary Sewage Systems 6?c' �f'eir �s� Permit .Number Name 5��� %(��7`,�,�r d�/r/l/. Date N2 N2 6893 Location�O'X//y- ..'// d r Subdivision Sec. or Block No, Lot Size House Mobile Home —T Business Speculation No. Bedrooms No. Baths No. in Family Garbage Disposal YES ❑ NO ❑ Specifications for System: Auto Dish Washer ' YES ❑ NO ❑ `�.' ��y Auto Wash Ma,.hine YES ❑ NO ❑ Type Water Supply *This permit Void if sewage sy em 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. Im rovementsermit b � Y-- *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: System Installed by�__A nn N d� � ono Certificate of Completion --ilai 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. APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERLAUG Davie County Health Department�, 5 92 Environmental Health SectignP. O. Box 665 Mocksville, NC 27028 1. Application/Permit Request d By /VA � J 7 'L/r � � Mailing Address .0 v1K % 5 e Co Home Phone 9 0 V 9s,/, Business Phone t r� 2. Name on Permit if Different than Above S /V1 ,,- =3. 3.Application/Permit for: ❑ General Evaluation Septic Tank Installation 4. System to Serve: Ouse ❑ Mobile Home ❑ Place of Public Assembly ❑ Business ❑ Industry ❑ Other ❑ Unknown L 5. If house, mobile home: Subdivision 6r)G! /` l A Section Lot # ❑ Basement/Plumbing No. of People ❑ Basement/No Plumbing No. of Bedrooms LJ 0 Washing Machine No. of Bathrooms In Dishwasher G r G 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: g21',Public ❑ Private 6 -Community 8. Property Dimensions ! s s ' 0 Sewage Disposal Contractor 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes No If yes, what type? *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: This is to certify that the information provided is correct to the best of my krn incurred fro thisq application. DATE I understand I am responsible for all charges SIGNATURE CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY MUST CHECK ONE: 1. I OWN the property. ❑ 2. 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 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) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation NAME 539E /&, ADDRESS PROPOSED FACIILTY DATE EVALUATED � 1 PROPERTY SIZE Aj LOCATION OF SITE 6//Gl' l � Water Supply: On -Site Well Community Public Evaluation By: Auger Boring Pit Cut Texture group Consistence FACTORS 1 2 3 4 Landscape position L L Slope % HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH Texture groupl Consistence ; Structure /ice Mineralogy HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION S LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: LONG-TERM ACCEPTANCE RATE: REMARKS: DCHD(01-901 EVALUATED BY: X/ OTHER(S) PRESENT: 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 Moiut 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 Mi neraloQy 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 DAVIE COUNTY HEALTH DEPARTMENT p. IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION *Note: Issued in Compliance with G.S. of North Carolina Chapter 130—Article 13c. Permit Number Name _ ` Date Location Subdivision Name Lot No. Sec. or Block No. Lot Size House Mobile Home _ Business Speculation No. Bedrooms No. Baths No. in Family Garbage Disposal YES p NO C]-- Specifications for System: l Auto Dish Washer YES p NO 0 Auto Wash Machine YES p NO p Type Water Supply _ *This permit Void if sewage system described below is not installed within 36 months from date of issue. r r I, Improvements permit by ' *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: System Installed by � �� r 1.,,, /7.� Certificate of Completion A. 6 ��� 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. e. DAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION *Note: Issued in Compliance with G.S. of North Carolina Chapter 130—Article 13c. Permit Number Name / Date Location Subdivision Name Lot No. Sec. or Block No. Lot Size House - Mobile Home — Business Speculation No. Bedrooms - Y No. Baths No. in Family Garbage Disposal YES ❑ NO ❑-'" Specifications for System: Auto Dish Washer YES ❑ NO ❑ `j' �' Auto Wash Machine YES ❑ f NO ❑ Type Water Supply n. "This permit Void if sewage system described below is not installed within 36 months from date of issue. Improvements permit bY... ' "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: 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. , 7 DAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION *Note: Issued in Compliance with G.S. of North Carolina Chapter 130—Article 13c. Permit Number Name , - - Date, Z Location Subdivision Name Lot No. Sec. or Block No. Lot Size House - Mobile Home _ Business Speculation No. Bedrooms No. Baths No. in Family Garbage Disposal YES ❑ NO ❑ �,. Specifications for System: Auto Dish Washer YES ❑ NO ❑ , Auto Wash -Machine YES ❑ NO -❑ Type Water Supply *This permit Void if sewage system described below is not installed within 36 months from date of issue. Improvements permit *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: 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. DOME COM = HEALTH DEPARTINMUT PERCOLATION TEST RESULTS DATEle��11 NA.,'iE— VIN LOCAIIO PIkIDINGS: HOLE 140. COMMENTS 2 Z By: LOT DIAGAILAI 0 IQ ------------- --Oc)9,i DAVIE COUNTY HEALTH DEPARTMENT P. 0. BOX 57 HOCKSVILLE, N. C. 27028 (704) 634-5985 Statement for Septic Tank Improvement Permits and/or Site -Evaluations NAME ADDRESS Explanation of charge DATE ISSUED .0 P,ERMIT NO. MZMR� AMOUNT DU SANITARIANZ;n� PLEASE REMIT THE ABOVE Al-IOU14T ON RECEIPT OF T -HIS STATEMENT.