P7925 Hwy 601S,
DAVUE COUNTY HEALTH DEPARTMENT
-' IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
°NOTE: |maued|nCornp|imnoeWith AmdeUofG.8.Chapter 13Oo
Sanitary Sewage Systems
Name Date
Location
Permit Number
N�� 7x�'��
��
o�� �
c .
�X0
'
Subdivision Name Lot No. Sec. o,Block No.
6-7
Lot Size Houoe----___-_ Mobile HomeBusiness --- |ndum\ry_______
No. Bedrooms —.No. Baths __r.��-__ No. in Family -__-__�-_ PublicAonombly______Othe[_______
Garbage Disposal YES 0 NO 'Specifications for System:
Auto Dish Washer YES [] NO ra~~''
AutoVVaoh Mu-hine YES .E]'NO [] `
Type VVotor Supply -_
-- --T---------' -
-
°Thinpa,mitVoid ifsewage system described below is not installed within 5years from date of issue.
This permit issubject \orevocation itsite plans orthe intended use change
ATTENTION: YOUR YOURSEPTIC SYSTEM CONTRACTOR MUST SEE THIS PERMITILAYOUT BEFORE INSTALLING THIS
'
Improvements permit by _-
^Oontactm representative of Davie County Health Department for final inspection of this system between 8:30-9:3OA.M,
1:00-1:30 P.M. or 4:30-5:00 P.M. on day of completion. Telephone Number: 704-634-5985�'��/60
Final Installation Diagram:
System Installed by
f�
__J/
O
(710
^
Certificate �Comp|��on Date
'The signing ofthis 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 oftime.
ti
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERN1IT.,
Davie County Health Department
Environmental Health Section
P. O. Box 665 F "ti"1 9 i�3:�
Mocksville, NC 27028
---------------
1. Application/Permit Requested By J -9 c r!4 1 e 1
Mailing Address 6 QL Q- c75/1' - S b,C f w Home Phone
d2 ? n e).5 Ui /1.e Sr' Business Phone
2. Name on Permit if Different than Above
3. Application for:
❑ General Evaluation
4. System to Serve: ❑ House
❑ Business ❑ Industr�7
5. If house, mobile home: Subdivision
No. of People 2
No. of Bedrooms 3
No. of Bathrooms
Dwelling Dimensions a 8 Y 15� el
E Septic Tank Installation Permit
D -Mobile Home
❑ Other
6. If business, industry, place of public assembly, other: Specify type
No. of People Served
No. of Commodes _
No. of Lavatories —
No. of Showers
2.
❑ Place of Public Assembly
❑ Unknown
Section Lot #
❑ Basement/Plumbing
❑ Basement/No Plumbing
El Washing Machine
❑ Dishwasher
❑ Garbage Disposal
No. of Sinks 3
No. of Urinals
No. of Water Coolers
�- Water Usage Figures
7. Type of water supply: Q- Public ❑ Private
8. Property Dimensions Z/0 X' 3 b 3 • Sewage Disposal Contractor
9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes 2- 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:
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.
3- /a - SS—
DATE SI NATURE
CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY
MUST CHECK ONE: N( 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 (1193)
•'1, C, RAY CATES certify that on S FPT. 01 1954, 1 surveyed the property shown on this plat:
that the property lines and location of all structures are accurately sh"dw.n hereon; that no structure located on this property
encroaches on any adjacent street or property, and that no structure on adjacent property encroaches on the premises
surveyed." I PARCEL
-- — — _ — rebor JERRY DANIEL
34. 01
C
found Fi JOHN SPILLMAN
S88° 22-5C,1 Eli D. B. I
63-440
282.20 1 Total 220.001
Iron N 050- 591- 301, E—>
P
110 new Iron
placed tI e I 10
D-1.163- 440 NORTH '+rrrC
C u C
33,419 SQ.FT to L =o 33,335 SQ.FT io L.
LPo
• N l
N "� 03 ro
00 ti O M
i Z N O`
I,.-2 -N
O W t70 0' O
� J to — t70 �� •-
N
to J a1) 00
4 i t z M
W ti to c
Q a m ^� M wt� A� ;Az C u o
e
(l O O PARCEL
bent ,ran Lound
167, 31' 41NO3••5fi
3W
t bent
- 35" E brat
found
04°.
=
(�
__
o_N
36'.10"E�
M
PARCEL
35.13
I _
— — — —
52.26'
x 0
1
O
to
I
1
'N
1
0
C
JOHN A. SPILLM
N.
1n IS
00
F-
to
ERVIN GRAY DANI
JAMES
ELs
i 1
Co"
N
JERRY DA
I EL
in
P
m
0.8. 142.364
to
00
1,800'2 to
JIJ
W w
V
S.Yodkn River
-- IranCL
a d
Placed
R /W
as cloirtted by
iron
a.
"0
Dloced N.C. OOT
I
'ran
placed
_ ____
"O
M
O
O�
point
I
x
1
110 IL
1
O
to
Point asphalt -7
I I 0
----
S 05°- 59- 251Wx
Total2
20.00
x point
U . S . HW Y. 6oi
PROPERTY OF
JAMES JERRY DANIEL and JEAN W.
PART OF 34. 01 , 35.13, 35.14 DAVIE COUNTY TAX MAP 0-6
LOT NO. MAP OF BLOCK NO.
PORTION OF 163 440 JERUSALEM TOWNSHIP,
DEE D BOOK 1 4 2 PAGE � 6 4 DAVIE-OUNTY, N. C.
SCALE: 1 INCH = 40 FEET
• roe No 3182
IOVTNCIIN 1•NOTO PAINT O PY►•lT CO.-WI949TOM.40AI11N NS0999
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
/ Soil/Site Evaluation / l
NAME C DATE EVALUATED
ADDRESS
PROPOSED FACIILTY
PROPERTY SIZE eOl> Y-16-0
LOCATION OF SITE
Water Supply: On -Site Well _ Community Public
Evaluation By: Auger Boring Pit Cut
FACTORS
1 2 3 4
Landscape position
L
Slope Z
HORIZON I DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH
` -y
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
LONG-TERM ACCEPTANCE RATE
SITE CLASSIFICATION: — � EVALUATED BY: __ /—&//
LONG—TERM ACCEPTANCE RATE: _ i 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- V+2ry 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
5C -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