722 Baileys Chapel Rd (2)' DAVIE COUNTY HEALTH DEPARTMENT v T�
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
NOTE: Issued in Compliance With Article II of G.S. Chapter 130a
Sanitary Sewage Systems
Name U N �� a �� N e -S Date .
�- f3 14 4 'N
ga y ..�o - �y
Permit Number
N27526
Location -IN- °y N
SubdivisionSec. or Block No.
Lot Size ✓� v CSS-, c House Mobile Home v Business -- Industry
No. Bedroe� – No: Baths _� No. in Family — Public Assembly Other
Garbage Dispos YES p NO p Specifications for S ste
Auto Dish Washer{ { YES Y .NO p
Auto Wash Ma^hine YES NO Q . O 0,
\x
Type Water Supply \-),a
Sti J
*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.
F
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.,
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:
System Installed by
r -
Certificate of Completion A40/ Date W
'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.
r
' APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PER 15------- (�
-� ~� • Davie County Health Department IRF f F � V E D
Environmental Health Section APR o
P. O. Box 665 8 1944
Mocksville, NC 27028
---------------
1. Application/Permit Requested By
Mailing Address Home Phone % / Qq
l?
*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:
�) 0 �' �/- �'� - le Vv- W;�v-
1 e° X"7—
"
"T
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 applicatiocn�.
/
DATE SIG ATU
CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY
MUST CHECK ONE: 91. 1 OWN the property. b -2-I 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 representativ f the D ie Co ty Hea h Department to enter upon above described
property located in Davie County and owned t,
to conduct all testing procedures as necessary to determine said site's suitab' ity f a ground absorption sewage treatment
and disposal system.
em-- )'6- 7�1--
DATE IGN URE
DCHD'(i/93)
Business Phone
2. Name on Permit if Different than Above
3. Application for: ❑ General
Evaluation Septic Tank Installation Permit
4. System to Serve: ❑ House
Mobile Home
❑ Place of Public Assembly
❑ Business ❑ Industry
❑ Other
❑ Unknown
5. If house, mobile home: Subdivision
Section Lot #
❑ Basement/Plumbing
'�
No. of People
❑ Basement/No Plumbing
No. of Bedrooms 3
P"Washing Machine
119
No. of Bathrooms --[Id
Dishwasher
�Z k 7
Dwelling Dimensions
❑ Garbage Disposal
6. If business, industry, place of public assembly, other:
Specify type
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
rivate
❑ Community
8. Property Dimensions
Sewage Disposal Contractor
9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes
0 -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:
�) 0 �' �/- �'� - le Vv- W;�v-
1 e° X"7—
"
"T
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 applicatiocn�.
/
DATE SIG ATU
CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY
MUST CHECK ONE: 91. 1 OWN the property. b -2-I 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 representativ f the D ie Co ty Hea h Department to enter upon above described
property located in Davie County and owned t,
to conduct all testing procedures as necessary to determine said site's suitab' ity f a ground absorption sewage treatment
and disposal system.
em-- )'6- 7�1--
DATE IGN URE
DCHD'(i/93)
�,'•=� DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
NAME
ADDRESS
PROPOSED FACIILTY
Water Supply: On -Site Well
Evaluation Bye �(VAuger Boring
DATE EVALUATED ` 2z�' — 1 I
PROPERTY SIZE
2
LOCATION OF SITEy � n,14 AQ
Community Public
Pit Cut
FACTORS
1
2
3
4
Landscape position
_19:--
s
-__Z_1
Sloe %.
kms►
7
3
'6
HORIZON I DEPTH
Texture group
-71
Consistence
Fr.
Structure
G
C R
R
c'
Mineralo
9
1'.l
lYl
HORIZON II DEPTH
3
f.
Texture group
Consistence
Structure
C
C__ I
Mineralogy
1 ; 1
I
VA
HORIZON III DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
5-3
s f
RESTRICTIVE HORIZON--
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE
SITE CLASSIFICATION: �\ 1 �D.
LONG-TERM ACCEPTANCE RATE: pp
REMARKS: \
DCHD (01-901
EVALUATED BY: 2a x�
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
To..f„�..
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
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