204-218 Granada 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 Permit Number
;r i 1�. 'S
Name L, //� ill �„ c ��` --- Date _ N2 8006
Location
Subdivision Names
Lot No. Sec. or Block No.
Lot Size '� %_
—
House —
Mobile Home Business — Business -- Industry
No. Bedrooms - r --.No.
Baths -z;7L--
No. in Family �/ — Public Assembly Other
Garbage Disposal
YES
p NO .-
Specifications, for System:
Auto Dish Washer
YES
NO pP12e-
�` �/
Auto Wash Ma -hive
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
ATTENTION:
YOUR SEPTIC SYSTEM CONTRACTOR MUST SEE THIS PERMITILAYOUT BEFORE INSTALLING THIS
SYSTEM.
Improvements permit by
*Contact a representative of the Davie County Health Department for final Inspection of this system between 8:30-9:301 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:
r -
foo
Certificate of Completion Lx— 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.
` y t
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section
P. O. Box 665
Mocksville, NC 27028
1. Application/Permit Requested B �--
Mailing Address .� Home Phone
v ✓� Business Phone !9
2. Name on Permit if Different than Above
3. Application for: ❑ General Evaluation
4. System to Serve: ❑ House
❑ Septic Tank Installation Permit
AMobile Home ❑ Place of Public Assembly
❑ Business ❑ Industry ❑ Other ❑ nknown
5. If house, mobile home: Subdivision aZL 7n Section Lot #
No. of People q
No. of Bedrooms
No. of Bathrooms -,-A -
Dwelling Dimensions Z `)`" X 76 — '?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: ❑ 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
ashing Machine
ishwasher
❑ Garbage Disposal
9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes ❑ 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:
This is to certify that the information provided is correct to
incurred from this application.
DATE
and I understand 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 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
DCHD (1/93)
SIGNATURE
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
NAMEy/l DATE EVALUATED
ADDRESS
PROPERTY SIZE
%2
-"/c-
Evaluation By:
PROPOSED FACIILTYT f?
LOCATION OF SITE
Cut
UIQ"
Ol'
Water Supply:
On -Site Well
— Community
Public ✓
Evaluation By:
Auger Boring f
Pit
Cut
FACTORS
1
2 3 4
Landscape position
4 -
Slope %
HORIZON I DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH
E'
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
i
SITE CLASSIFICATION:
LONG-TERM ACCEPTANCE RATE:
REMARKS:
DCHD(01-901
EVALUATED BY: 114 l
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 :lay loam SIL -Silty loam CL -Clay loam SCL-Sandy clay loam
SC -Sandy clay SIC -Silty clay C -Clay
CONSISTENCE
Moist
VFR- V? ---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
Mineralog
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
M
0- SEC. 1 55 N
Q
0 9 P.B. 4, 1280 rn
\� 147.97 56 o
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SWIMMING POOLS 0 58
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13 ..A.. / CLUB HOUSE %i 61lu� O
13
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72 \\��612 �o 'fes, 143.54 N
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ZIP
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73
II
LA QUINTA °o
SEC. 2 10 890 60
60
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