128 Ferns Wayf, 13 x 1:F f3'4 ..�^.,r . {
r v 1 � ,_ .rw�s F (i t. ��`.� ry-,. i'�:`yt ,�!�,�.e s� x. t`.F"� w .tL; �.'�jt7 l�'=•S �� �1 /• 0
DAVIE COUNTY HEALTH DEPARTMENT
� lao. iii
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTE: Issuedin Compliance With Article 11 of G.S. Chapter 130a
- Sanitary Sewage Systems Permit Number
-Name ` : Date ND
t. 637`'
Location �'_ , 4 , e r N:: ; k
�, c� � 1 � � \ • .T, 'CtrsVAl-
_
.,.
}„J
Subdivision Name Lot No. Sec. or Block No.
Lot Size House l-�' Mobile Home _T Business Speculation
No. Bedrooms No. Baths �-- No. in Family
—
Garbage Disposal YES ❑ NO 0, Specifications for System:
Auto Dish Washer. YES ❑ NO p•
Auto Wash Ma thine YES �? NO ❑
Type Water Supply (7
*This permit Void if sewage system described below is not installed within 5 years from date of issue
Thispermit 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 -�` ��"q,.'..._
"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 RECp APR.• R
P. 0. Box 665
Mocksville, NC 27028
1. ADDlication/Permit Recuested By � � L . Nu Ck n Ls-
Mailing
S
Mailing Address 10.+1 11 96X C0((
Home Phone 6o 4 ! 76 1 Business Phone
2. Name on Permit if Different than Above 6-4M£
3. Property Owner if Different than Above MME
4. Application/Permit For: 0 General Evaluation S/Tank Installation
5. System to Serve: X House 0 Mobile Home 0 Business
0 Industry G Other 0 Unknown
6. If house, mobile home: Subdivision Sec. Lott
No. of People Dwelling Dimensions S -O" 38'
No. of Bedrooms g Basement/Plumbing
No. of Bathrooms Basement/No Plumbing
'Washing Machine J Dishwasher 0 Garbage Disposal
7. If business, industry, other: Specify type
No. of People Served
No. of Commodes
No. of Lavatories
No. of Showers
8. Type of water supply: k Public
9. Property Dimensions %SGCY"es
No. of Sinks
No. of Urinals
No. of Water -Coolers
0 Private
0 Community
10. Sewage Disposal Contractor /y d t A nQ w /l X— m C_-
11. Do you anticipate additions/expansions of the facility this system is
intended to serve? 0 Yes X 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.
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. -� Q
.41—g— ! / C;; • T�
Date Signature
Directions to Property:
(9 ¢ GJ p S � rZfteM �1�2e- A
�u v
DCHD (10-89)
c - DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
NAME
ADDRESS 5 trs
PROPOSED FACIILTY 0% S o
DATE EVALUATED q' _�)_9'' 9l
PROPERTY SIZE
LOCATION OF SITE ,) IIYSO o
Water Supply: On -Site Well Community
Evaluation By�Z'�\-. Auger Boring V Pit
Public
Cut
FACTORS
1
2
3
4
Landscape position
Sloe %
- a
1b- ISD
-15"
-i y
HORIZON I DEPTH
"
C `'
L, "
Texture group
C"
C t_
C L-
C L_
Consistence
F1
PT
F-
-
Structure
99
G +;
Q
G
Mineralo
tJ
) . 1
7-5-1:
HORIZON II DEPTH
Texture groupC
C
C
Consistence
-•Z
F2
-L
Structure
A$t-'
Mineralogy
HORIZON III DEPTH
Texture group
Consistence
Structure
r"
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
S 5
5S
RESTRICTIVE HORIZON
SAPROLITE
_
CLASSIFICATION
S
R S
S
S
LONG-TERM ACCEPTANCE
RATE 3S-, o
,35-,
. S--
SITE CLASSIFICATION: X • �-> EVALUATED BY: C • Z�'��
LONG-TERM ACCEPTANCE RATE: ��5 - �� 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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