165-181 Canterbury LnYX0
DAVIE COUNTY HEALTH DEPARTMENT 5f�
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTE: Issued in Compliance With Article 11 of G.S. Chapter 130a l�l�
Sanitary Sewage Systems Permit Number
Name �O/jh U11,21e Dat "f-� N2 68,49
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Location
Subdivision Name Lot No. Sec. or Block No.
Lot Size �*� House Mobile Home Business _— Speculation
No. Bedrooms �� No. Baths , No. in Family _/ _
Garbage Disposal YES ❑ NO
Specifications for System:
Auto Dish Washer YES NO ❑ �G�lj� /`_
Auto Wash Ma shine YES NO ❑ U
Type Water Supply
'JtwG l,ri,x/W pry
*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.
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J
Improvements permit by _ 'fit! /
*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
f`
Cert
'The signing of this certificate shall indicate
the standards set forth in the above regulatioi
satisfactorily for any given period of time.
in compliance with
a system will function
a
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section
P. O. Box 665 dr
Mocksville, NC 27028
1. Application/Permit Requested By
Mailing Address- Z.2
Home Phone 9S - 3// 3 Business Phone
2. Name on Permit if Different than Above
3. Application/Permit for:
4. System to Serve:
❑ Business
❑ House
❑ Industry
5. If house, mobile home: Subdivision
No. of People
No. of Bedrooms
No. of Bathrooms ��JJ
Dwelling Dimensions
❑ General Evaluation
"obile Home
❑ Other
6. If business, industry, place of public assembly, 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
Water Usage Figures
7. Type of water supply: ❑ Public ¢ �rivate
8. Property Dimensions � Qzcei- e !� f Sewage Disposal Contractor
,�7- V"��
P'Septic Tank Installation
❑ Place of Public Assembly
❑ Unknown
Section Lot #
❑ Basement/Plumbing
❑ Basement/No Plumbing
2"Washing Machine
2"bishwasher
❑ Garbage Disposal
9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes 0 -mo
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: Zc77t C 7 6-0 )/'7L',
17,
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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 application. /
DATE A SIGRATURE
CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY
MUST CHECK ONE: el. 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:
1 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. n n , _ 0.
DATE .i" SIWATURE
DCHD (12-90)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
NAME
ADDRESS
PROPOSED FACIILTY e' k/
DATE EVALUATED
PROPERTY SIZE>��
LOCATION OF SITE
Water Supply: On -Site Well bl_�' Community
Evaluation By: Auger Boring ✓ Pit
Public
Cut
FACTORS 1
2
3
4
Landscape position A.
C
L
L
Slope %
—
—
'—
HORIZON I DEPTH
Texture group
Consistence
Structure
MineralogX
HORIZON II DEPTH tfk
Texture group
Consistence
17_11
101 1
Structure S� _
X';1
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: &
L.ONG-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 watef 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
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