241 Bell Branch Rd (2)s
c DAVIE COUNTY HEALTH DEPARTMENT
or
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
'NOTE: Issued in Compliance With Article 11 of G.S. Chapter 130a
Sanitary Sewage SysteT/ Permit Number
Name � �v �i�i,a//Jic� N2 7 7 5 9
Location –�C%� /fir i� ,.l;fJ �/ y
.f i�5'�,7 ,✓l- Si
Subdivision Name Lot No. Sec. or Block No.
Lot Size House Mobile Home _ Business -- Industry
No. Bedrooms No. Baths— No. in Family_ Public Assembly Other
Garbage Disposal YES ❑ NO Specifications for System:
Auto Dish Washer YES NO ❑ - d°
Auto Wash Ma shine YES NO ❑ �w Grp
Type Water Supply Ami /f
'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: Jr �r;,,�_2- 3 System Installed by S
X04- dee- 21"
q 4 2 ka. D RJQ
Z17212
l l
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
Davie County Health Department
• Environmental Health Section
P. O. Box 665
Mocksville, NC 27028
1. Application/Permit Requested By `--Z--( /
Mailing Address 94. Home Phone qq'� ' 5:�(e// ai
klWc0b�`�h a Business Phone
2. Name on Permit if Different than Above ,L,1R \� �LoQt �jMX\APn
3. Application for:
4. System to Serve:
❑ Business
❑ General Evaluation �ptic Tank Installation Permit
ouse ❑ Mobile Home ❑ Place of Public Assembly
❑ Industry
5. If house, mobile home: Subdivision
❑ Other
No. of People — 4
No. of Bedrooms
No. of Bathrooms T,
Dwelling Dimensions
6. If business, industry, place of public assembly, other: Specify type
No. of People Served
No. of Commodes
No. of Lavatories
No. of Sinks
No. of Urinals
No. of Water Coolers
❑ Unknown
Section Lot #
'L�asement/Plumbing
❑ Basement/No Plumbing
®'Washing Machine
8-6shwasher
❑ Garbage Disposal
No. of Showers WaterZivate
a Figures
7. Type of water supply: ❑ Public ❑ Community
8. Property Dimension4_2..-T yV /000 Sewage Disposal Contractor
9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes 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:
"�Yo011WLC�A 1Q4 ot_ &_1V_J
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.
f
DAT
CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY
MUST CHECK ONE: QY1. 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:
I hereby give consent to the authorized representative of the avil Jotntyealth Department to enter upon above described
property located in Davie County and owned by
to conduct all testing procedures as necessary to�ine aid -sire's suitability for a ground absorption sewage treatment
and disposal system.
m` — %
T I DATE
DCHD (1193)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
NAME DATE EVALUATED 110 0
ADDRESS
PROPERTY SIZE /tire
PROPOSED FACIILTY LOCATION OF SITE 4,11
Water Supply: On -Site Well Community Public
Evaluation By: Auger Boring Pit Cut L'.tf'
FACTORS
1
2
3 4
Landscape position
4
Sloe Z
2
HORIZON I DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH
f
+
t -
Texture groupT
Consistence
Structure
5,6
Mineralogy
7.7
%`
/ '
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: ff r /
LONG-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
SILL -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