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1—
==- DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMITkAND CERTIFICATE OF COMPLETION
'* NOTE: Issued in Compliance With Article I I of G.S,Chapter 130a
Sanitary Sewage Systems fi, -- ,_ _._ - Permit Number
Name ��. Date N_ 710 5
Location Y �'t. `f v 'k r., c (') � l u 0,
f,) \ � \• � F-. i,� ``_' C*T—.�11 :.. .._;5.1.:-• .1'.. �1 ��.\ C i ' ;V\ .,,
Subdivision Name
Lot Size
House
No. Bedrooms y No. Baths 1 s
Lot No.
Block No
Mobile Home —T Business Speculation
No.. in Family 4 —
Garbage Disposal YES ❑ NO ❑ Specifications for _System:
Auto Dish Washer YES ❑ NO ❑ i ��'`' �;<�"a `� .:,..: �:•. C`���-c
Auto Wash Ma -.bine YES NO ❑ 1� U Y k ;� 1-• �-�
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.
-In
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 Diagrar"
system Installed by
Certificate of Completion/ 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 R�!� )®
Davie County Health Department .a
Environmental Health Section APR - 5 1993
P. O. Box 665
Mocksville, NC 27028 _ -------------
1.
_________
1. Application/Permit Requested By'
Mailing Address �Z 14�d
Home Phone��Q0' Business Phone
2. Name on Permit if Different than Above
3. Application/Permit for:
4. System to Serve: 1540use
❑ Business ❑ Industry
5. If house, mobile home: Subdivision
❑ General Evaluation
❑ Mobile Home
❑ Other
No. of People
No. of Bedrooms
No. of Bathrooms /
Dwelling Dimensions
6. If business, industry, place of public assembly, other: Specify type
No. of People Served No. of Sinks _
No. of Commodes No. of Urinals
Septic Tank Installation
❑ Place of Public Assembly
❑ Unknown
Section Lot #
W/Basement/Plumbing
❑ BasemenUNo Plumbing
P -Washing Machine
❑ Dishwasher
❑ Garbage Disposal
No. of Lavatories No. of Water Coolers
No. of Showers Water Usage Figures
7. Type of water supply: M --public ❑ Private c❑�.�Community
8. Property Dimensions CreS Sewage Disposal Contractor
9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes ONo
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:
1'7 %t o use
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.
f7a:4 p47i
DATE 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
If
disposal system.
DATE SIGNATURE
DCHD (12-90)
i
• = DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
NAME
ADDRESS
PROPOSED FACIILTY
Water Supply: On -Site Well
Evaluation Byl'-",'. Auger Boring
DATE EVALUATED
PROPERTY SIZE
LOCATION OF SITE
Community
Pit
Public
Cut
FACTORS
1
2
3
4
Landscape position
S
S
S
-S'
Slope
HORIZON I DEPTH
Texture group
0 L
L
L
G L
Consistence
F -T
__X
- 7
Structure
G V_
010,
G
R
Mineralogy
11.1
I :
I
: 1
HORIZON II DEPTH
2,`'
2
�l0
Texture groupL°
Consistence
-
Structure
LL
Mineralogy
HORIZON III DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
S
SS
SS
RESTRICTIVE HORIZON
—
—
SAPROLITE
—
—
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE
SITE CLASSIFICATION: _ \'�' EVALUATED BY: rs_
LONG-TERM ACCEPTANCE RATE: �� OTHER(S) PRESENT:&+.
REMARKS: V.,
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
DCHD(01-901