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332 La Quinta Drive� 1 DAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENTS PERMIT AND . CERTIFICATE OF COMPLETION *NOTE: Issued in Compliance With Article II of G.S. Chapter 130a Sitary Sewage Systems_ Permit Number —�V Name t�//;nn� ,J/ ���.:�✓r,., Date �/ �i �f N2 i C7 6526 q Location Subdivision NameQ °'`�y�'¢L« � Lot No. Sec. or Block No. Lot Size - House Mobile Home I, Business Speculation No. Bedrooms . 2 No. Baths -- No. in Family Garbage Disposal YES ❑ NO a Auto Dish Washer. YESNO ❑ Auto Wash Ma :hive YES [� NO ❑ Type Water Supply Specifications for System: *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: IV u System Installed b� r Certificate of Completion 1 Y 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 PERMIT Davie County Health Department Environmental Health Section P. O. Box 665 Mocksville, NC 27028 1. Application/Permit Requested By _ �4'',5 0 L 6 /I%Ci Mailing Address r-242-0 14 IM i J E Home Phone ��� J � / Business Phone. 2. Name on Permit if Different than Above 3. Application/Permit for: ❑ General Evaluation 4. System to Serve: ❑ House E -Mobile Home ❑ Business ❑ Industry ❑ Other 5. If house, mobile home: Subdivision No. of People No. of Bedrooms `3 No. of Bathrooms Z—� Dwelling Dimensions a 9 X G 6. If business, industry, place of public assembly, other: Specify type L" Septic Tank Installation ❑ Place of Public Assembly ❑ Unknown Section Lot # ❑ Basement/Plumbing ❑ Basement/No Plumbing 2 -Washing Machine 'Dishwasher ❑ Garbage Disposal 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: tfiPublic ❑ Private ❑ Community 8. Property Dimensions Sewage Disposal Contractor 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes EJ -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 knowledge, and I understand I am responsible for all charges incurred Irompis application. / 1�..,c�e �2 i' DATE SIGNATURE . CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY MUST CHECK ONE: 1. I 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 dispos sy em. Ai/ DATE SAONATYRE DCHD (12.90) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation NAME ocy1 DATE EVALUATED ADDRESS PROPERTY SIZE PROPOSED FACIILTY LOCATION OF SITE Water Supply: On -Site Well Community Public [l--' Evaluation By: Auger Boring 6 Pit Cut FACTORS 1 2 3 4 Landscape position L Slope Z — - - 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: _ rV - S LDNG-TERM ACCEPTANCE RATE: REMARKS: DCHD(01-901 EVALUATED BY: 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 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 DAVIE COUNTY HEALTH DEPARTMENT SEPTIC TANK PPERMIT Date — Oimer/Occ t Lo To: Addre s / Q9�� Address 7/// Building Contractor ��' Address xv Cal. p p Manufacturer's Name A Arcess No. of Imes Width 3 (�in. Total length /`� ft. No. sq. ft. 3 YI7 Type of filter material Total tons used o2.3 Hinimum REquirements: House Trailer Tank cap. 800 Sq. ft. line 400 Two-bedroom house 800 600 Three-bedroom house 900 900 No one shall install a septic tank in Davie County without a permit from the Health Offi< or his agent. Date of Final Approval Signed: Sanitarian I hereby certify that the above septic tank has been installed according oto/specificatio? .Signed: Sepkic Tank Contractor Note: Make sketch of disposal system on back of sheet and mail to Davie County Health Center, Box 57, Mocksville, North Carolina 27028.