294 Blaise Church RdDAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND . CERTIFICATE OF COMPLETION
- ~ *NOTE: Issued in Compliance With Article 11 of G.S. Chapter 130a
Sanitary Sewage Systems a� Permit Number
Name�,�`,'%!...>rf>r�11,.//r Date -�i' N2
Location%
Subdivision Name Lot No. Sec. or Block No.
Lot Size moi'!House Mobile Home i % Business Speculation
No. Bedrooms No. Baths— No. in Family__
Garbage Disposal YES ❑ NO Specifications for System:
Auto Dish Washer. YES p NO ❑
Auto Wash Ma shine YES 0 NO ❑
Type Water Supply
*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 P.M. on day of completion. Telephone Number 704-634-5985.
Final Installation Diagram: System Installed by
Certificate of Completion Date_.
'The signing of this certificate shall indicate that the system described above j a§, lrreen 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.
C
1. Application/Perm
Mailing Address ,U
Home PhoneBusiness Phone
2. Name on Permit if Different than Above
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section
P. O. Box 665
Mocksville, NC 27028
IA1T
3. Application/Permit for: ❑ General Evaluation
4. System to Serve: ❑ House Dlaobile Home
❑ Business ❑ Industry ❑ Other
5. If house, mobile home: Subdivision
No. of People 121
No. of Bedrooms
No. of Bathrooms —
Dwelling Dimensions
6. If business, industry, place of public assembly, other: Specify type
No. of People Served No. of Sinks
Septic Tank Installation
❑ Place of Public Assembly
❑ Unknown
Section Lot #
❑ Basement/Plumbing
❑ Basement/No Plumbing
❑ Washing Machine
❑ Dishwasher
❑ Garbage Disposal
No. of Commodes No. of Urinals
No. of Lavatories No. of Water Coolers
No. of Showers Water Usage Figures
7. Type of water supply: ❑ Public 2r0iivate
8. Property Dimensions�Sewage Disposal Contractor
9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes
If yes, what type?
■
❑ 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:
6F/ 9
4a-.5-0 - 4J 10-cle
This is to certify that the information provided is correct to the best of my
incurred from this application.
—
DATE
and I understand I am responsible for all charges
SIGNATURE
CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY
MUST CHECK ONE: ❑ 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
S it/Site Evaluation
0
NAME _ 1�
ADDRESS
PROPOSED FACIILTY
DATE EVALUATED
PROPERTY SIZE 455i e__
LOCATION OF SITE
Water Supply: On -Site Well f// Community
Public
Evaluation By: Auger Boring Pit Cut
FACTORS 1
2
3 4
Landscape position
Sloe %
HORIZON I DEPTH
Texture group
Consistence
Structure
MineralogX
HORIZON II DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON III DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION FT
LONG-TERM ACCEPTANCE RATEI
Al
SITE CLASSIFICATION: Vr
6U EVALUATED BY: Z''
LONG-TERM ACCEPTANCE RATE: OTHER(S) PRESENT:
REMARKS:
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
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
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