359 Boxwood Church Rd (2).. :.. .,. '• Tye ,
�:.. ... 1, •:_... 1 ', .,.'.. .v :_., . . v'.�.n � ;, 3"p.t ._ . . ,
DAVIE COUNTY HEALTH DEPARTMENT ;JQo,
0
- IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTE: Issued in Compliance With Article 11 of G.S. Chapter 130a
Sanitary Sewage Systems Permit Number
Name ��l�tv Q A���� 4���.5 Date N2 7 512
Location �U e (Z ?N %J `N o c�S U ��\� 1V �L1oaz
4 U1 s - 1 , �., ..nom CLQ. - o-� *u �. ..�o v�41
I I..>.. \ V
Subdivision Name Lot No. Sec. or Block No.
Lot Siie-sem- House Mobile Home _ Business _— Industry
No. Bedrooms No:"Baths — .No. in Family — Public` Assembly Other
Garbage Disposal YES C] NO E� Specifications for System:
Auto Dish Washer YES p/ NO ❑ i OD
Auto Wash Ma shine YES Ep/NO ❑
Type Water Supply _ 01.6 u 'vv"
.T .
*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 pl ns or,the intended use,change.
• /ao
t= ,
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.,
1:00-1:30 P.M. or 4:30-5:00 P.M. on day of completion. Telephone Number: 704634-5985.
Final Installation Diagram:
System Installed bya-- -,
RIC
CIL
Certificate of Completion s -75-"5� Date 1 21 -
'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 II��
Environmental Health Section �IC OVE
P. O. Box 665 ^ 7 1984
Mocksville, NC 27028 APR
1. Application/Permit Requested Byo.//^Q/�fi� CSN �F" &JtV/('� - -
Mailing Address 11 : JePF- Gk ri -!� P— Home Phone 6 3 9- 15FC54
16 -�buz ZZ 0- i Business Phone � .3 y -/O 6x d 9
2. Name on Permit if Different than Above
3. Application for: ❑ General Evaluation is Tank Installation Permit
4. System to Serve: ❑ House Q_Gebile Home ❑ Place of Public Assembly
❑ Business ❑ Industry /J ❑ Other / ❑ Unknown
5. If house, mobile home: Subdivision 01rZoa ( h rJ Section Lot #
❑ Basement/Plumbing
No. of People '3 ❑ Basement/No Plumbing
No. of Bedrooms 5 O -Washing Machine
No. of Bathrooms C�— 8 -Dishwasher
Dwelling Dimensions �l X 7 ❑ Garbage Disposal
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: K�-ru—blic ❑ Private
8. Property Dimensions 4 (1 C f ,;:!� Sewage Disposal Contractor
9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes M -No -
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: //
'CG �.,-cGr
/ heAr -
�C{C d- A) � V � rc�✓�� �D
of /'le ) "'J
b�q , � Aaee6�
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
incurr from this application.
ATE SIGNATURE
CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY
MUST CHECK ONE: Com. I 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 (1/93)
DAVIE COUNTY HEALTH DEPARTMENT
r Environmental Health Section
` Soil/Site Evaluation u
NAME 11 q.\ t N2 j"K.t imS DATE EVALUATED
ADDRESS PROPERTY SIZE
PROPOSED FACIILTY �� �� LOCATION OF SITE
Water Supply: On -Site Well Community
Public
Evaluation By.( fjL- Auger Boring ✓ Pit Cut
FACTORS 1
2
3
4
Landscape position
-S
Sloe % 6
5
HORIZON I DEPTH
4 "
`13,14
Texture groupL
L
S C -
Consistence YZ
t -
Structure
MineralogyI•►
:1
►
HORIZON II DEPTH
at,
Texture group
Consistence
F
�-
Structure `F
B
Mineralogy
HORIZON III DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
_5
3
S
RESTRICTIVE HORIZON--
SAPROLITE —
--
CLASSIFICATION
-7-7—.
e.
,S
LONG-TERM ACCEPTANCE RATE Ll
X4
4
SITE CLASSIFICATION: �� ' S EVALUATED BY:
LONG-TERM ACCEPTANCE RAT; 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 +.lay 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
MISSIONARY
CHugcvi
P G
b 551
- 486
1.81
23 8. 10 TOTAL
0
0
0
0
0
tt�
746
1
cy
v
c;
on
pip
I -
E-1,710 51, 20 " E!Z
=1 elp
31.21 361.21 TOTAL
!T
CHRISTOPHER TODD
FLANAGAN'
D8.134 PG. 550
316.40
e%—
632.82
1
DANA MICHELLE F. POTTS
DS. 134 PG. 5 49
Elp b 316.04
330.00 NIP 243.29
S 710 51' 20 " w
JAMES H, HAYES 20 1 EASEMENT
D8. 154 PG. 360
PRIVATE DRIVE
AREA = 2.000 ACRES
14 W
(INCLUDES S. R. 1824 R/W.) 0 to
3OJ5 273.00 TOTAL NIP
S 680 26 48 W JOE B,
NIP 2.01 PAVED 242115 N DB. 81
00
REA•
ACRE 0 0
INCLU S 1824 R/W 0 N 700 28' 41"E
L4—
TAKEN FROM DB- 148 P6.213 NIP
.0oN- 80.09
26g gg
%. S NIP
C;5
N 5 23g 31
NIP
E
-5.000 ACR
L) ARE:A
1619 R/W
, 4
S R
CLU DE
GRUBB
G I N ALD PG - 213
m 148
0
0
0 SR �819
m
C"F'ftft'f 15 ?.g
zi 36
P. K
00 03
NAIL S
FLANAGAN
PG. 298
141P
16 Vy
NAIL
z6y4'I \4 P,\j f- 0
o
1150 ZOS50-4ms
j! Y I ri A
tAACOi BY ':-0-
ot