454 Bonkin Lake Rdi F , � ys� a...a. } .{; , . v. _ . . -.i l• r .. n� .J ",.a a err i - a , . .. .,�'A._x .1
DAVIE COUNTY HEALTH DEPARTMENT
t IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION ;
*NOTE: Issued in Compliance With Article II of G.S. Chapter 130a
Sanitary Sewage Systems Permit Number
Name `� �`�� �Date N°_ 6954
Location ` 5 �= �, �. `'� �',� V. t, ft. n
Subdivision Name o o. Sec. or Block No.
Lot Size �' " ^" House Mobile Home Business -- Speculation
No. Bedrooms No. Baths No. in Family } _
Garbage Disposal YES ❑ NO [I Specificatiorts for System:
Auto Dish Washer YES Ef NO 0
Auto Wash Ma shine YES E'j NO ❑ i i �= �` '�--_ , ' >, J + �:, _�`
Type Water Supply
*This permit Void if sewage syItem described below is not installed within 5 years from date of issue.
AJ
This permit is subject to r ocat•onlf site plans or the intended use change.
DO
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a
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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: , w
�S S
System Installed by IIA
-30-9'3
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.
✓,, ' P P APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMITFNO
Davie County Health DepartmentEnvironmental Health Section P. O. Box 665
Mocksville, NC 27028 n 1 ""q-=
7
1. Application/Permit Requested By t`\ 0
Mailing Address 4590
Home Phone(919) 18i -ez% Business Phone (`104 �3�—`F�q� KA
2. Name on Permit if Different than Above Sl{Me A-5 / koe - —/
3. Application/Permit for: E) General Evaluation l" Septic Tank Installation
/
4. System to Serve: 2 House ❑ Mobile Home ❑ Place of Public Assembly
❑ Business ❑ Industry ❑ Other ❑ Unknown
5. If house, mobile home: Subdivision
No. of People 3
No. of Bedrooms 3
No. of Bathrooms A
Dwelling Dimensions
Section Lot #
❑ Basement/Plumbing
❑ Basement/No Plumbing
2"Washing Machine
eDishwasher
❑ 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 Water
Usage Figures
7. Type of water supply: ❑ Public L" Private
8. Property Dimensions a °� aces Sewage Disposal Contractor
9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes
If vac what tvna'?
(R 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: 65;,- PJ �a1k; talco �dvC
HWH Sot
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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.
DATE I NO SIGNATURE
CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY
MUST CHECK ONE: Ed 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 He Ith Department to enter upon above described
C-4
property located in Davie County and owned by m"'1 P't'AM-e r- �� ' 4YmeA
to conduct all testing procedures as necessary to etdrminb said site's suitability for a ground absorption sewage treatment
and disposal system.
DATE SIGNATURE
DCHD (12-90)
DAVIE COUNTY: H 44TH ' DEPARTMENT
Envirommntal Health Section
Soil/Situ Evaluation q
NAME `\,\ \\\ �\- DATE EVALUATED
ADDRESS 5 �"S' PROPERTY SIZE C
PROPOSED FACIILTY \\\X ° 9 LOCATION OF SITE
Water Supply: On -Site Well Community Public
Evaluation By:� yL Auger Boring V Pit Cut
FACTORS
1
2
3
4
Landscape position
—S
S
.—S
Sloe %
-
—771 —S"
T s
` 15
HORIZON I DEPTH
Texture group
C` L
C
C L
Consistence
za
Structure
CR
MineralogX
HORIZON II DEPTH
a 0
.. 0,
Texture group
C.
Consistence
v:
Structure
Mineralogy�\
'•
i
HORIZON III DEPTH
2) 10b
c�
Texture group
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
.S775
RESTRICTIVE HORIZON--
SAPROLITE
S
CLASSIFICATION
5
LONG-TERM ACCEPTANCE RATE
'
I,
SITE CLASSIFICATION: `l • S ^ EVALUATED BY:
LONG-TERM ACCEPTANCE RATE: d OTHER(S) PRESENT:\
REMARKS:
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 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