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3978 Hwy 158 (3)f I � DAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENTS PERMIT AWCERTIFICATE CERTIFICATE OF COMPLETION *NOTEAssued in Compliance With Article 11 of G.S. Chapter 130a - Sanitary Sewage Systems Permit Number Name '. �� m �i/ff, /: Date , .n -i NO 6789 Loc ion I *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. ( 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. 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 v V Date � r "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. Subdivision Name Lot No:, Sec. or Block No. Lot Size House Mobile Home Business Business Speculation No. Bedrooms No. Baths No. in Family Garbage Disposal YES ❑ NO Specifications for System: Auto Dish Washer YES ❑ NO Auto Wash Ma :hive YES ❑ NOType Water 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. ( 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. 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 v V Date � r "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. E► APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERM Davie County Health Department Environmental Health Section } P. O. Box 665 ` Mocksville, NC 27028 1. Application/Permit Requested By a ZnAn !1t 0- : $ n `v1 Mailing Address TY' Home Phone' �' �i — (1 % ! Business Phone 2. Name on Permit if Different than Above 3. Application/Permit for: 4. System to Serve: ❑ Business ❑ General Evaluation ❑ House 9 Mobile Home ❑ Industry ❑ Other 5. If house, mobile home: Subdivision No. of People _ o`— 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 Commodes No. of Lavatories No. of Sinks No. of Urinals No. of Water Coolers No. of Showers Water Usage Figures 7. Type of water supply: ❑ Public [Private 8. Property Dimensions 170 Sewage Disposal Contractoi 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? If yes, what type? MAY -1-3'M GvmPL�`77oi✓ �-i� = [l""Septic Tank Installation ❑ Place of Public Assembly ❑ Unknown Section Lot # ❑ Basement/Plumbing ❑ Basement/No Plumbing 02( Washing Machine ❑ Dishwasher ❑ Garbage Disposal ❑ Yes 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: 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 f � DATE SIGNATURE CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY MUST CHECK ONE: 11 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 If disposal system. DATE SIGNATURE DCHD (12-90) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section y , Soil/Site Evaluation �! a NAME ��t/ DATE EVALUATED �2f /mac ADDRESS PROPERTY SIZE Z 407 PROPOSED FACIILTY LOCATION OF SITE�i Water Supply: On -Site Well Community Public Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3 4 Landscape position L L Z Slope % — -- HORIZON I DEPTH Texture group Consistence Structure MineralogX HORIZON II DEPTH 3 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 7-2 LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: _ e� C/ LONG-TERM ACCEPTANCE RATE: 7 REMARKS: DCHD(01-901 EVALUATED BY: _ _ , &,2 ZZ OTHER(S) PRESENT: 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 ■NEEMENME■■■■ ■E■M■MENN■EM■ ■■M■■■MENNEE■ ■■ME■EMENN■E■ ■EM■■EMEMOMME ■■ENE■MEMMEM■ ■EMEMEME■EM■■ ■EMMEME■EMEN■ ■WEENN■EMMEN■ ■EMEM■MME■■M■ ■ENEEN■■■MMO■ ■ENNEMEMMEM■■ ■■