329 Georgia Rd (2)I�Y
DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
f� *NOTE: Issued in Compliance With Article II of G.S. Chapter 130a if
Sanitary Sewage Syste s Permit Number
Name �' Date - 0 6121
Location
Subdivision Name Lot No. Sec. or Block No.
Lot Size2" I) �) _ House Mobile Home _%� Business Speculation
No. Bedrooms No. Baths No. in Family _
Garbage Disposal YES ❑ NO pSpecifications for , System:
Auto Dish Washer YES NO ❑ j�`,/
Auto Wash Machine YES 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.
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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:
System Installed by
f��
Certificate of Completion ZZ Date -�
"The signing of this certificate shall indicate that the system described above has been installed in compliance with
the standards set forth ' he above regulation, but shall in NO way be taken as a guarantee that the system will function
satisfactorily for any given. erip od of time. ` �
1. Permit F
2. Address
3. Property
Address
4. Permit Ti
APPLICATION FOR SITE EVALUATION/ IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section
P. 0. Box 665
Mocksville, N.C. 27028.
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
iv
Home Phone
Business Phone
b) Privy Conventional ✓ Other Type
Ground Absorption
c) Sub -Division Sec. Lot No.
5. System used to serve what type facility: House Mobile Home ✓ Business
IndustryOther
b) Number of people
6. a7 If house or mobile home, state size of home and number of rooms.
House Dimensions
Bed Rooms Bath Rooms_ Den w/Closet_
b) If Business, Industry or Other, State: Number of persons served
What type business, etc.
Estimate amount of waste daily (24 hours)
7. Number and type of water -using fixtures:
commodes urinals garbage disposal
lavatory ca showers washing machine
dishwasher ✓ sinks
8. a) Type water supply: Public Private ✓ Community
b) Has the water supply system been approved? Yes No
9. a) Property Dimensions goo X /000
b) Land area designated to building site
c) Sewage Disposal Contractor
10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve?
What type?
This is to certify that the information is Corr ct to the best of my knowledge.
7 U1 (Y)• at��q—\
Date Owner Signature QS
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
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DCHD )6-82) /
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�-" DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
NAME DATE EVALUATED Cil✓�/
ADDRESS PROPERTY SIZE
PROPOSED FACIILTY /'/ll /►/ LOCATION OF SITE z�l
Water Supply: On -Site Well Community Public
Evaluation By: Auger Boring Pit Cut
FACTORS
1
2
3
4
Landscape position
L
L
L
L
Sloe %
1/
HORIZON I DEPTH
Texture group
Consistence
Structure
MineralogX
HORIZON II DEPTH
L 1
Texture group'
Consistence
Structure
Mineralogy
r;
/.'
/'
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
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SITE CLASSIFICATION: EVALUATED BY: ,�-4 /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
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
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DCHD (01-901 � vl