1094 Ben Anderson Rd79 ti, ��W v �s.v r..i fir. �.,� _ f•F;M y ..w. � i,,;cp„_. .. ,�,F,,itiy�i'v"'yzr ;-=�``57r �ta`a .. .(i !,.- .i °... , ti - .r. e. ,- R,
`. DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTE: Issued in Compliance With Article 11 of G.S. Chapter 130a
S nitary Sewage Systems - C 1 Permitor
Name Date NO
Location
��, ��� � 1 J �'\; i.'l� ;�,`��J,T���`.�„� ��.�. ��, {j � �1f`, `� f5 K3.C� l�g;r.9'?� \.�\ � I' �, � i (\ \. -, .'iC ••
Subdivision N e 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 Spec System: _
Auto Dish Washer YES„ NO F1
Auto Wash Ma shine YES ❑ NO
Type Water Supply
'This permit Vpid,lf"sewage,system described below is not ins' Iled withn 5 years from date of issue.
This permit �s su j c�t�tdlev�ation if site plans or the intend d ase change.
i.w
is permit by
*Contact a representative of the Davie County Health Departalent. for ?hal inspection of this system between 8:30-
9:30 A.M. or 1:00-1:30 P.M. on day of completion. Telephte Nu er7/04-634-5985.
-AIJI
LA
Final Installation Diagram: TSystfiled by eUr� C_�`
;
r T
Certificate of Completion—_x/&// 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.
r�
r APPLICATION FOR SITE EVALUATIOWIMPROVEMENTS PER
Davie County Health Department
Environmental Health Section
P. O. Box 665 7AU
Mocksville, NC 27028
1. Application/Permit Requested By No n n i' e— '� O e6o -Yl
Mailing Address G T�> nX 2 S- ACLoon 1" e- /VC— oq rZ,0,0 /-
Home Phone (9 y `' 9 �k— -,;76 19 Business Phone
2. Name on Permit if Different than Above
3. Application/Permit for
4. System to Serve:
❑ Business
❑ General Evaluation
House ❑ Mobile Home
❑ Industry ❑ Other
5. If house, mobile home: Subdivision
No. of People 7
No. of Bedrooms 3
No. of Bathrooms 42
Dwelling Dimensions 3 J( /o o?
6. If business, industry, place of public assembly, other: Specify type
No. of People Served
No. of Commodes
No. of Lavatories
No. of Showers
No. of Sinks
No. of Urinals
No. of Water Coolers
Water Usage Figures
7. Type of water supply: ��❑ Public "IQ Private
,Property Dimensions jD Sewage Disposal Contractor
9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes
Septic Tank Installation
❑ Place of Public Assembly
❑ Unknown
Section Lot #
❑ Basement/Plumbing
❑ Basement/No Plumbing
`� Washing Machine
'M Dishwasher
If yes, what type?
❑ Garbage Disposal
No
❑ Community
`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: �� N -;LO /—t �j erLl���G` jGt ,-/i./
Chi u le- C-14 RO/ he, (V k � 6 AJ Bei i3�c�e�sor� i�c� • �o �-o
4 -A -e, en cl a 4h fZoa cl .c�4 ,env �,ea.r, c e_ oil l�� • Ccs
Ccs s s cle-1-U�P-, WO.1
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 applicat9S
i
DATE ` SIGNATURE
CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY
MUST CHECK ONE: `�l1 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
and disposal system.
DATE SIGNATURE
DCHD (12-90)
-» DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
NAME a a u i e —ZY 0 R, A�
ADDRESS 5 A tri'
PROPOSED FACIILTY N\0 J S2
Water Supply: On -Site Welly
Evaluation By:C"L— Auger Boring
DATE EVALUATED <)) L� 3
PROPERTY SIZE Co �-
LOCATION OF SITE
Community Public
Pit Cut
FACTORS
1 1
3
4
Landscape position
Slope 7.
d -ems
d g�
a-5°
CC'S
HORIZON I DEPTH
'
Texture groupL--
Consistence
F
-
Structure
V_.
C
Mineralogy
HORIZON II DEPTH
zJ2 11
:1
Texture group
CE.
Consistence
-
l -
Structure
Mineralogy
HORIZON III DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
S
s
S S
.SS
RESTRICTIVE HORIZON
—'
SAPROLITE
—
CLASSIFICATION
S
@, 5.
$ .5
S
LONG-TERM ACCEPTANCE RATE
3
SITE CLASSIFICATION: 's EVALUATED BY: F►�\
LONG-TERM ACCEPTANCE RATE: _ 3 OTHER(S) PRESENT:
REMARKS: ��� s PO q -T-
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