185 Lakeview Road Section 2 Lot 47ij
DAVIE COUNTY HEALTH DEPARTMENT
(Septic Tank) Improvements Permit and> Certificate of Completion
i0w (Ground Absorption Sewage Disposal System - G.S. Chapter 130 -Article 13C)
OWNER OR ' CONTRACTOR . l ',..y . sl - . ' 1' t�of '6j
DATE ": h{ p 77
PERMIT
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-LOCATION �t
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1659
S.R.
NO.
SUBDIVISION NAME LOT NO. SECTION`; OR
BLOCK NO.
HOUSE MOBILE HOME BUSINESS. ❑
.
House Trailer X800
Gal. 400
Sq. Ft.
NO. BEDROOMS NO. BATHROOMS
Two Bedroom House 800
Gal. 600
Sq..Ft.
GARBAGE DISPOSAL UNIT YES Z NO- ❑
Three Bedroom House b900
Gal. 900
Sq. Ft.
AUTO. DISHWASHER YES C3 NO f3Four
Bedroom House 1e000
Gal. 1200
Sq. Ft.
AUTO. WASH. MACHINE YES ❑ NO ❑
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SITE SUITABLE YES ❑ NO, M
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SIZE OF TANK gal.
° 'y
NITRIFICATION FIELD sq.' ft.
DEPTH OF STONE IN LINES:`
WATER SUPPLY:Individual ❑ Public
IMPROVEMENTS PERMIT BY A.'l',.1
INSTALLED BY
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CERTIFICATE OF COMPLETION,. By
(8/16/73): *Construction must comply with all other applicable State
LOT AREA
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Date •r/f/L(��� /
id local regulations
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DAVIE COUNTY HEALTH DEPARTMENT
P. 0. BOX 57
MOCKSVILLE, N. C. 27028
(7 04) 634-5985
Statement for Septic Tank Improvement Permits
and/or Site Evaluations
NAME -k,tl l- DATE ISSUED 1n-.;25=77
ADDRESS �;-� j. .. PERMIT NO.
Explanation of chargee ,. 4,,,4 - ,(,�i � 4.1
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AMOUNT DUE /S• �` SANITARIAN��
PLEASE REMIT THE ABOVE AMOUNT ON RECEIPT OF THIS STATEMENT.
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department
" Environmental Health Section
P. O. Box 665
Mocksville, NC 27028
l
1. Application/Permit Requested By
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Mailing Address 0 441 /A A , N cS- Home Phone /-
oc, t`�{ / (UC -7 n 2 Business Phone r! 3 ZZZZ
2. Name on Permit if Different than Above
3. Application for: a- eneral Evaluation ❑ Septic Tank Installation Permit
4. System to Serve: Ouse ❑ Mobile Home ❑ Place of Public Assembly
❑ Business ❑ Industry ❑ Other ❑ Unknown
5. If house, mobile home: Subdivision Section Lot #_
❑ Basement/Plumbing
No. of People 3 ❑ Basement/No Plumbing
No. of Bedrooms 3 ❑ Washing Machine
No. of Bathrooms Z?- ❑ Dishwasher
Dwelling Dimensions 6y i 3a-f'� ❑ Garbage Disposal
6. If business, industry, place of public assembly, other: Specify type N A
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.�3 ElPrivate
8. Property Dimensions I �14� ��e � • .� k 130 + �-/Sewage Disposal Contractor
9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes
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: /
5/ra� -,z;' ml cwt l� , Ga✓� T a Z -4
Q. 6,±—;
vs Cs J�. 9 ( See / J re.✓gW11 2 / JT,' W
This is to certify that the information provided is correct to the best of my
incurred from this applicati n.
DATE
and lyc30erstand I am responsible for all charges
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 fom MUST be completed by the owner or a person authorized by the owner:
I hereby give consent to the authorized representati", the Davie�Qunty �H�e�Ith Department to enter upon above described
property located in Davie County and owned by w.SZLI % c.1 e- '
to conduct all testing procedures as necessary to determine said site's suitability for a ground absorption sewage treatment
and disposal system.
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DATE SIGNATURE
DCHD (193)
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2.40.0 (L _ 174.16
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246.87
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NAME
ADDRESS
PROPOSED FACIILTY
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
DATE EVALUATED �'� ,9 S/
PROPERTY SIZE /s e �XJ-:2 / d
LOCATION OF SITEC !1 1"e,
Water Supply: On -Site Well Community Public z-/
Evaluation By: Auger Boring Pit Cut
FACTORS
1
2 3 4
Landscape position
L
Slope %
—
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: EVALUATED BY: !/
LONG-TERM ACCEPTANCE RATE: OTHER(S) PRESENT:
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-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
5C -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)
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Davie County Aealtli Department 10
and Nome NealtFi .�,T �e
en Le
210 HOSPITAL STREET/ P.O. BOX 665 �,J '
MOCKSVILLE. N.C. 27028
PHONE: (704) 634.5985 I�
December 14, 1994 I)
T. Kyle Swicegood
300 South Main St.
Mocksville, NC 27028
Re: Site Evaluation
Hickory Hill/Section 2—Lot 47
Dear Mr. Swicegood:
As requested, a representative from this office visited the aforementioned
site on December 13, 1994. Based upon the information provided on the
application for site evaluation and after the evaluation was completed, the
site was found to be provisionally suitable for the installation of an on—site
sewage disposal system.
If you have any questions, please feel free to contact this office.
Sincerely,
Robert B. Hall, Jr., R.S.
Environmental Health Section
RH/wd
Enclosure