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DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION u c�
*NOTE: Issued in. Compliance With Article II of G.S. Chapter 130a
Sanitary Sewage Systems Permit Number
Name ' �S 'Q�C"�S - !' 4 rr= T:Date N° {�
.�
Subdivision Name Lot No. Sec. or Block No.
Lot Size - House Mobile Home __ Business Speculation —x
No. Bedrooms No. Baths No. in Family
Garbage Disposal YES ❑ O 21.1� Specifications for System:
Auto Dish Washer. YES gK NO ❑ C30
Auto Wash Ma thine YES lel' NO ❑
Oct
Type Water Supply CCJ, n��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 plans or the intended use change.
mit by
*Contact a representative of the Davie County Health Ddpartmeit for final ins ction f this system between 8:30-
9:30 XM—or 1:00-1:30 P.M. on day of completion. Tel phonellNumber 704A34-5985.\
Final Installation Diagram:
Installed
le, fi
►Gu. �, "k
Certificate of Completion "'J Date 2- Z�
TJ
*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.
0
APPLICATION FOR SITE EVALUATION/ IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028 00
CONSTRPCTION SHALL NOT BEGIN UNTIL 1
Cl / roan
(Permit Requested By 6
2. Address
3. Property Owner if Different than Above
Address
PROVEMENTS PERMIT HAS
..1 01
Home Phone
Business Phone f�
z4("�
4. Permit To: a) Install Alter Repair
b) Privy Conventional-&:'_'10ther Type
Ground Absorption
q
c) Sub -Division Sec. Lot No.—,E
o.—.7—
7 " -3
5. System used to serve what type facility: House Mobile Home Business
IndustryOther
b) Number of people
6. ap If house or mobile home, st to size of home and number of rooms.
House Dimensions ZVX',6
Bed Rooms 3 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 I?—
lavatory
dishwasher
urinals
showers
sinks l
8. a) Type water supply: Public ✓Private Community
garbage disposal
washing machine l
b) Has the water supply system been approved? Yes No
9. a) Property Dimensions ��� .7
b) Land area designated to building site F► �� T�
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 co c to the of my knowledge.
Date Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
DCHD (6-82)
Ala CM' /U__'
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
NAME
ADDRESS
PROPOSED FACIILTY m c�
DATE EVALUATED IP - 7 - QI
PROPERTY SIZE
LOCATION OF SITE J,5r-- 4- R -9-Q
Water Supply: On -Site Well Community
Evaluation ByC'�,i— Auger Boring_ v Pit___
Public.
Cut
FACTORS
1
2
3
4
Landscape position
S
S'
s-
--�
Sloe %
F is
Fr -77
77 T"
HORIZON I DEPTH
'Fr'°
S"
e''cc
'r
Texture group
L_
C I-
C '_
O_ L_
ConsistenceF-'r
I
r -L
Q1Y
Structure
P
C e
C P
Q
Mineralogy
tl
1 41 1
; 1
HORIZON II DEPTH
y b
L)I-)^
p'1
v "
Texture group
(I
<`
C.
Consistence '
F T
F -L
)-1
I ---I
Structure
Air
Mineralogy
HORIZON III DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
Ss
,S�s
5s
RESTRICTIVE HORIZON
—
-
SAPROLITE
—
-
-
CLASSIFICATION
S
S
P -S
p_c
LONG-TERM ACCEPTANCE RATE
,9-_ o
_ p
,33- J
,35�-,Ll
SITE CLASSIFICATION: _ W S' EVALUATED BY: (2
LDNG-TERM ACCEPTANCE RATE: 03� -' 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
DCHD(01-901
NOME
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