295 Bell Branch Rdh' DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND, CERTIFICATE OF COMPLETION ;
*NOTE: Issued in Compliance With Article II of G.S. Chapter 130a
anitarySewage Systems Permit Number
r
Name,/r%'''r/:4r/r'a;`�'rT'�1/I%,�/!f Date .,.��; N2 6195
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 p- Specifications for System:
Auto Dish Washer YES NO ❑ �<
Auto Wash Machine YES NO -❑ a .
l.r i a`I �,.,y i E w z b e i—"� t"i✓114r+y k
Type Water Supply .lam'%
*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.
Q_
Improvements permit by — ,Z //
*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
Certificate of Completion ZL__— 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.
S
M APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section
P. 0. Box 665 RECEIVED OCT
Mockaville, NC 27028 Z 2
1. Application/Permit Requested By MA4d �%e --.1..li/h.Y�G-aim �
Mailing Address 0—/ 9 &,e 331 Mne-ksys 1 {r,
Home Phone ;;W- - 733 �- Business Phone 2L� 2,3 3 y
2. Name on Permit if Different than Above
3. Property Owner if Different than Above
4. Application/Permit For: lC) General EvaluationVIS/Tank Installation
System to Serve: House LYMobile Home 0 Business
Industry u Other 0 Unknown
6. If house, mobile.home: Subdivision Sec. Lot#
No. of People Dwelling Dimensions 141 X �/po
No. of Bedrooms 0 -- Basement/Plumbing
No. of Bathrooms / Basement/No Plumbing
(/Washing Machine J Dishwasher 0 Garbage Dispusai
�tS�91
If business, industry, other: Specify type
No. of People Served
n
No. of Commodes
�J No. of Lavatories
r�
No. of Showers
8. Type of water supply: V Public
9. Property Dimensions ,57 4r..-•- 7-
10. Sewage Disposal Contractor
No. of Sinks
No. of Urinals
No. of Water Coolers
V15'r,ivate
a Community
11. Do you anticipate additions/;70'r
cions of the facility this system isintended.to serve? [] Yes
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 t
best of my knowledge, and
charges incurred from the
�)- x, ( 910
Date
Directions to Property:
DCHD (10-89)
ie information provided is correct to tree
I understand I am responsible for all
a application.
A.
®�
cocA Lib-er•y ekjrr--k 4-0r bel\ brahcl•\
2 nhov5r . on t--r--N,
I
M1
DAVIE COUNTY HEALTH DEPARTMENT
` Environmental Health Section
Soil/Site Evaluation
NAME _�/�� 9,1,-&_" '
ADDRESS
PROPOSED FACIILTY "% eg
DATE EVALUATED -!o�p
PROPERTY SIZE
LOCATION OF SITE
Water Supply: On -Site Well Community Public
Evaluation By: Auger Boring Pit Cut
FACTORS
1 2
3
4
Landscape position
Sloe Z
HORIZON I DEPTH
o2
2
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH
Texture group
Consistence
r
Structure
,r
.N
Mineralogy/-
/ -
J.- /
/.•
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: i
LONG-TERM ACCEPTANCE RATE:
REMARKS:
DCHD(01-901
EVALUATED BY: xe1/
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 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