262 Hobson DriveDAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTE: Issued in Compliance With Article 11 of G.S. Chapter 130a
Sanitary Sewage Systems J__�/-<it Number
y
Name `rDate
Location n %�—/ "/� / �'��'f,'r,� � � •:��� G:- ,�'�!%,�;J,'� ,,, '— ,,� � `
-- —
/r
Subdivision Name
Lot No. Sec. or Block No.
Lot Size r;� r-'
House
Mobile Home — Business _— Speculation
No. Bedrooms =
— No. Baths —va�
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 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 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:
F
Certificate of Completion )%G 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.
j APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department Q
Environmental Health Section CCQ
P. 0. Box 665 RGC�
Mocksville, NC 27028
1.
Application/Permit
Requested By
ULU-4-- A -AC daIV'
,
Mailing Address
r'�''� ` �i,-t �C
/
J�y `1 5 b u.�y iy ,cs=r�
Home Phone
63.7
Business Phone
-20V - (n 3 (,
2.
Name on Permit if
Different than
Above
3.
Property Owner if
Different than
Above �� ;� 1L-,,
AL4 i��C
4.
Application/Permit
For: l7 General'Evaluation
5/Tank Installation
S.
System to Serve:
0 House
Q,-Kobile Home
0 Business
Industry
u Other
0 Unknown
6.
If house, mobile home:
Subdivision
Sec. Lot#
No. of People
Dwelling Dimensions
11
f 1C 17(D
No. of Bedrooms
Basement/Plumbing
No. of Bathrooms
-Basement/No Plumbing
leashing Machine
0-
Dishwasher
0 Garbage Dlsposai
7. If business, industry, other: Specify type
No. of People Served
No. of Commodes
No. of Lavatories
No. of Showers
8. Type of water supply: E;,PUblic
9. Property Dimensions add
10. Sewage Disposal Contractor
No. of Sinks
No. of Urinals
No. of Water Coolers
0 Private
0 Community
11. Do you anticipate additions/expansions of the facility this system is
intended to serve? 0 Yes -340
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.
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 applicatj.,on.
8)
Date Signature
Directions to Property:
71 d -n- %oI'd, ; -?Ifo e��
h, use
DCHD (10-89)
,.
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
NAME W_U'2!Z
ADDRESS
PROPOSED FACIILTY
Water Supply:
Evaluation By:
DATE EVALUATED �? "/ Z'
PROPERTY SIZE a�p
LOCATION OF SITE
On -Site Well Community
Auger Boring Ll__� Pit
FACTORS 1 2 3 4
Landscape position t— 4--
Slope
--
Slo e % 10—
HORIZON I DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH
Texture group
Consistence
Structure
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
SITE CLASSIFICATION:;,
LONG-TERM ACCEPTANCE RATE:
REMARKS:
DCHD(01-901
EVALUATED BY: A
OTHER(S) PRESENT:
LEGEND
Public
Cut
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
'r-fil-
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
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