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" m IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
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Sanitary Sewage Svabamu Permit Number
Name
Date Locati
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Subdivision Name Lot No. Sec. orBlock No.
Lot Size _-____Houoo_--____- Mobile Home _- Business __-_--__|ndustry________ '
No. Bodronmo"�_'__ No. Baths No. in Family -__��---_ Pub|ioAmsamb|y_______Othe[_______
Garbage Disposal YES [] NO
Specifications for System:
Auto Dish VVeuhor YES NO
Auto Wash Ma-hine YES NO
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Type Water Supply--
*This permit Void lf sewage system described below innot installed within 5years from date ofissue.
This permit iusubject torevocation ifsite plans orthe intended use ch6nge
ATTENTION: YOUR SEPTIC SYSTEM CONTRACTOR MUST SEE THIS PERMIT/LAYOUT BEFORE INSTALLING THIS
SYSTEM. '
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Improvements permit by
°Dontacte representativeofthe Davie County Health Department for final inspection of this between 8:3O-9:3OA^N1,
i:0O'1:3OP.7N.or4:30'5:00P.M.onday of comp|aVm�.Telephone Number: 704'U34'6986 -F7.160
41
Final
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System Installed by
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Certificate of Completion Oohe
'The signing of this certificate shall indicate that the system described above has been installed in compliance with
the standards set forth inthe above regulation, but shall inNO way betaken aaoguarantee that the system will function
satisfactorily for any given period oftime.
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section
R E CS O h9'1Qp
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P. O. Box 665
' Mocksville, NC 27028
HA - 1 19f
1. Application/Permit Requested By
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Mailing Address t,^,l`� p����nn Home Phone
Wy U.in I Business Phone
2. Name on Permit if Different than Above
3. Application for: a General Evaluation Septic Tank Installation Permit
4. System to Serve: ❑ House Mobile Home
❑ Place of Public Assembly
❑ Business ❑ Industry ❑ Other
❑ Unknown
5. If house, mobile home: Subdivision Section
Lot #
❑ Basement/Plumbing
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No. of People
❑ Basement/No Plumbing
No. of Bedrooms
EP/Washing Machine
No. of Bathrooms iL
VDishwasher
Dwelling Dimensions
❑ Garbage Disposal
6. If business, industry, place of public assembly, 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 Watery Usage Figures
7. Type of water supply: ❑ Public p' Private
❑ Community
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8. Property Dimensions 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: �0 I d id +z)f,L)
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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. ,
95 ads vs3
DATE SIGNATURE
CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY
MUST CHECK ONE: 1. 1 OWN the property. ❑ 2. I 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 (1193)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
NAME ���✓ DATE EVALUATED
ADDRESS PROPERTY SIZE
PROPOSED FACIILTY ,LY!9�y LOCATION OF SITE
Water Supply: On -Site Well _ Community Public
Evaluation By: Auger Boring "I', Pit Cut
FACTORS 1 2 3 4
Landscape position
Sloe Z 7.
HORIZON I DEPTH
Texture group
Consistence
Structure
MineralogX
HORIZON II DEPTH 1`—
Texture groupn n
Consistence
Structure
Mineralogy y
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:
EVALUATED BY: /V14-6
LONG-TERM ACCEPTANCE RATE: '.Z OTHER(S) PRESENT:
REMARKS:
DCHD(01-901
LEGEND
Landscave 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 ;lay loam- SIL -Silty loam CL -Clay loam SCL-Sandy clay loam
SC -Sandy clay SIC -Silty clay C -Clay
CONSISTENCE
Moist
VFR- V -y 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
3C --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