539 Becktown Rd;✓y DAVIE COUNTY HEALTH DEPARTMENT
�[ID � IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTE: Issued in Compliance With Article 11 of G.S. Chapter 130a
'Sanitary Sewage Systems Permit Number
Name f f, l �+.J a' ``, �1'�7?; Date N2 5971
Location f
Subdivision Name Lot No. Sec. or Block No.
Lot Size:jam a C House Mobile Home—1,�'Business _ Speculation
No. Bedrooms— No. Baths No. in Family _
Garbage Disposal YES ❑ NO [p' Specifications for System:
Auto Dish Washer YES TNO ❑ < ti J
Auto Wash Machine YES NO ❑ �'�'
r it
Type Water Supply
C�119404JA'i,-4
*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 R.M. on day f completion. Telephone Number: 704-634-5985.
Final Installation Diagram: System Installed by `r-%
Certificate of Completion Date �S
*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 APR 17 10
Mockaville, NC 27028
1. Application/ Permit Requested By
Mailing Address " 2 TaN 3 Qc),oalxeC- 92700
Home Phone
aJl V-3 2 Business Phone
2. Name on Permit if Different than Above
3. Property Owner if Different than Above
4. Application/Permit For: 0 General Evaluation Tank Installation
5. System to Serve: House bile Home Business
Industry �0 u Other 0 Unknown
6. If house, mobile home: Subdivision Sec. Lot#
No. of People Dwelling Dimensions /(//S '2__
Fwo
No. of Bedrooms 7 Basement/Plumbing
.No. of Bathrooms Basement/No Plumbing
BG)ashing Machine J Dishwasher 0 Garbage D:isposai
7. If business, industry, 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
8. Type of water supply: ublic Private 0 Community
9. Property Dimensions
10. Sewage Disposal Contractor
11. Do you anticipate additions/expansions of the facility this system is
intended to serve? G Yes 3—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.
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.
/ 7 ':�D � zf���
Vate Signature
Directions to Property: J6
holix
-/Jla"C�5
_44
DCHD (10-89)
rk
- DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
NAME �� DATE EVALUATED
ADDRESS PROPERTY SIZE
PROPOSED FACIILTY ��ry LOCATION OF SITE _�l('`dAtu✓
i
Water Supply:
On -Site Well '
Community
Public
Evaluation By:
Auger Boring
Pit
Cut
Texture group
Consistence p4
F!'
FACTORS 1— `"
2 3 4
Landscape position
Sloe Z
HORIZON I DEPTH
'Z per
Texture group
Consistence p4
F!'
Structure
S'
Mineralogy/
HORIZON II DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON III DEPTH
- -
Texture group
Consistence
Structure
Mineralogy
HORIZON IV DEPTH t
Texture group1
Consistence -
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE
SITE CLASSIFICATION: V
LONG-TERM ACCEPTANCE RATE: L
REMARKS:
DCHD(01-901
EVALUATED BY: _ ,r,2'eZ
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
P,
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
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