P6588 Childrens Home RdDAVIE COUNTY HEALTH DEPARTMENT H
r IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
urs,
*NOTE: Issued in Compliance With Article II of G.S.-Chapter 130a -r
Sanitary Sewage Systems Permit Numbb j
Name l-, r?��f` �. �' % �" ii,�'i_ Date l f <%1 No
Subdivision Name
Lot No. Sec. or Block No.
Lot Size House Mobile Home's Business Speculation
No. Bedrooms —.No. Baths e�2_ No. in Family_
Garbage Disposal YES ❑ NO
Specifications for System:
Auto Dish Washer YES ❑ NO
Auto Wash Ma.hine YES ❑ NO
Type Water Supply /9/ r� _ . %S` i✓ % ' ` X
*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./
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: Systefi Installed by
Certificate of Completion ,Zla Date ,11;.6 -9Z
*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.
iar V
t. APPLICATION FOR SITE EVALUATION/IMPROVEMENTS P
Davie County Health Department
Environmental Health Section
P. O. Box 665
Mocksville, NC 27028
1. Application/Permit
Mailing Address _
2oml Phone
0.
2. Name on Permit if Different than Above
3. Application/Permit for:
4. System to Serve:
❑ Business
-use
❑ Industry
5. If house, mobile home: Subdivision
No. of People
No. of Bedrooms
No. of Bathrooms
Dwelling Dimensions
//e e-, e
Business Phone
❑ General Evaluation
ovil -bile Home
❑ Other
6. If business, industry, place of public assembly, other: Specify type
No. of People Served —31 ZE ,-s—
No. of Commodes
No. of Lavatories
No. of Sinks
No. of Urinals
No. of Water Coolers
No. of Showers Water age Figures
7. Type of water supply: El Public Private
8. Property Dimensions Sewage Disposal Contractor
9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? Yes ❑ No
If yes, what type? kZn (I . -4-1
F�I�✓F_
NOV 0 7 1991
VSeptic Tank Installation
❑ Place of Public Assembly
❑ Unknown,
Section Lot #
❑ Basement/Plumbing
❑ Basement/No Plumbing
❑ Washing Machine
❑ Dishwasher
❑ Garbage Disposal
❑ 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:
zd7 � U e,j —Rd act D rd
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This is to certify that the information provided is correct to the best of my knowledge, and I understand I am
incurred from this application.
!Z/
DATE
CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY
MUST CHECK ONE: &J""1. I 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 abs&6bon 96Wage treatment
and disposal system.
,
1Z- ,"7-71`
DATE
DCHD (12.90)
A*
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
NAME cl�D e"& DATE EVALUATED�yjl/
ADDRESS PROPERTY SIZE
PROPOSED FACIILTY LOCATION OF SITE loO1�
Water Supply: On -Site Well f Community Public
Evaluation By: Auger Boring c� Pit Cut
FACTORS
1 2 3 4
Landscape position
L L
Sloe %—
HORIZON I DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH
Texture group
Consistence
,
Structure
/1
Mineralogy
HORIZON III DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
S
LONG-TERM ACCEPTANCE RATE
��- y
SITE CLASSIFICATION: IA -JS
LANG -TERM ACCEPTANCE RATE:
REMARKS:
DCHD (01-901
EVALUATED BY: �14 &
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
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