1622 Angell RdDAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTE• Issued in Com liance With Article II of G S Cha for 130a
Sanitary Sewage Systems
Permit Number
Name ,��� :��_z �r\ �'4_�`� Date r) L, i
N0 6266
Location --, f \'� .� M\ -Z `
•.>,.>.��s.s, •z�--. �,:''�>.s.�,'�. � �-�.�i�, \?_� ct��`:..:_ �.._��v,.cz. • r�'i�_r�. .Sl.zr�f?
'Sec.
Subdivision Name C Lot No. or Blo
Lot Size House Mobile Home —++f/� Business
Speculation
No. Bedrooms- No. Baths No. in Family �L �—
Garbage Disposal YES ❑ NO E�
Specifications for System:
Auto Dish Washer YES ❑ NO [
,� ) c,Srkt
Auto Wash Machine YES Ep,- NO❑'
ilk
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
System Installed by W J
-rt
� q
Certificate of Completion Date -` I
'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. 0. Box 665 RECEIVED ) 7 tv
Mockaville, NC 27028
1. Application/Permit Requested By .STin n( L 6 Y L 0H /i. Dr/? -S
Mailing Address //?0 T £ C5 8 d X (.23
Home Phone (9/9) 998- 3 1 7.2 Business Phone A
2. Name on Permit if Different than Above
3. Property Owner if Different than Above —"
4. Application/Permit For: C) General Evaluation S/Tank Installation
5. System to Serve: C) House Y-' Mobile Home 0 Business
0 Industry u Other 0 Unknown
6. If house, mobile home: Subdivision Sec. Lot#
No. of People Dwelling Dimensions /.? X $d
No. of Bedrooms Basement/Plumbing
No. of Bathrooms / Basement/No Plumbing
-g./,Washing Machine J Dishwasher 0 Garbage Disposal
7. If business, industry, other: Specify type
No. of People Served
No. of Commodes
No. of Lavatories
No. of Showers
No. of Sinks
No. of Urinals
No. of Water Coolers
8. Type of water supply: C Public Private a Community
9. Property Dimensions—_8 A ce z S
10. Sewage Disposal Contractoi-
11. Do you anticipate additions/expansions of the facility this system is
intended to serve? [I Yes 0 N
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 incu red from this applicatio .
/ 9
U to Signature
Directions to Property:
DCHD
At, olu 60 I 1`.'7�
RlgoN NivAR�
L r-FON 4A)gell 'RJ O.6 n:
c-2 sd'oRy 0 NlT£ �0u s C.
0 N RiGN7,
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
' Soil/Site Evaluation
NAME . ;� DATE EVALUATED
ADDRESS S 4.'C� " PROPERTY SIZE is C pp
PROPOSED FACIILTY (�t� LOCATION OF SITE..a7�
Water Supply: On -Site Well IJ Community
Evaluation By?� .k,�. Auger Boring V Pit
Public
Cut
FACTORS
1
2
3
4
Landscape position
.S
.5
c
Sloe Z
9-
_
-
HORIZON I DEPTH
e�'
$'
Texture group
L_L
Consistence
x.
Structure
C
Mineralogy
1
HORIZON II DEPTH
41q
d"
Texture group
Consistence
V71
1
Structure
A
k
Mineralogy
HORIZON III DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
S
S S
S S
RESTRICTIVE HORIZON
—
—
SAPROLITE
CLASSIFICATION
YS
LONG-TERM ACCEPTANCE RATE
5 -.40
J
-,40 1
135 •-, b
,3S-. o
SITE CLASSIFICATION: %`4 • �
LONG-TERM ACCEPTANCE RATE: °3
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
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
Mi neraloity
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