P8123 Hwy 601S9#Ry" 1
1` DAVIE COUNTY HEALTH DEPARTMENT P � f%
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETIO S
'NOTE: Issued in Compliance With Article II of G.S. Chapter 130a
Sanitary Sewage Systems Permit Number
%.� Date — 1
N 8123
Name ."rt�r�,' / /T J / f:u, r _— 0
Location 2�, _ �/�� �, r2,
Subdivision Name Lot No. Sec. or Block No.
Lot Size -% % _"` — House — Mobile Home �!�_ Business -- Industry
No. Bedrooms ?--.No. Baths
No. in Family — Public Assembly Other
Garbage Disposal
YES ❑ NO
Imo'
Specifications for System:
Auto Dish Washer
YES ❑ NO
❑;,
l �jl//
Auto Wash Ma :hive
YES j NO
❑
Type Water Supply —__
�!
-_--- ---
,.7.lI,r,`.J�,�
'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
ATTENTION: YOUR SEPTIC SYSTEM CONTRACTOR MUST SEE THIS PERMIT/LAYOUT BEFORE INSTALLING THIS
SYSTEM.
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.,
1:00-1:30 P.M. or 4:30-5:00 P.M. on day of completion. Telephone Number: 704-634-5985: ?'140
Final Installation Diagram:
I System Installed by
Certificate of Completion %-- Date —
*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.
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS
Davie County Health Department
Environmental Health Section
P. O. Box 665
Mocksville, NC 27028
1. Application/Permit Requested By ��e r !I/IN) I
Mailing Address o R Home Phone d� yS
Business Phone 5 A-;� r-
2. Name on Permit if Different than Above
3. Application for: ❑ General Evaluation EMeptic Tank Installation Permit
4. System to Serve: ❑ House
❑ Business ❑ Industry
5. If house, mobile home: Subdivision
No. of People _
No. of Bedrooms
P -Mobile Home
❑ Other
No. of Bathrooms
1�2-
Dwelling Dimensions •ye X "-) X
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
❑ Place of Public Assembly
❑ Unknown
Section Lot #
❑ Basement/Plumbing
❑ Basement/No Plumbing
❑ Washing Machine
❑ Dishwasher
❑ Garbage Disposal
No. of Showers Water Usage Figures
7. Type of water supply: E 'ublic ❑ Private /� El Community
8. Property Dimensions �� D X 3� 3 Sewage Disposal Contractor 1 .4",0/,�-
9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes 8 -No
If yes, what type?
*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: /I
�
1•e )v0�, �Ivev�9e- eV
Te
lob �` r
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.
DATE SIGNATURE
CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY
MUST CHECK ONE: le i. I OWN the property. ❑ 2. I 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
and disposal system.
DATE SIGNATURE
DCHD (1193)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
NAME 0"i'e / DATE EVALUATED
ADDRESS PROPERTY SIZE
PROPOSED FACIILTY ,X�` LOCATION OF SITE
Water Supply:
On -Site Well
_ Community
Public
Evaluation By:
Auger Boring
Pit
Cut
FACTORS
1
2 3 4
Landscape position
,L
L
Slope %
-,
HORIZON I DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH
Texture groupG
Consistence
i
Structure
S
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:
LONG-TERM ACCEPTANCE RATE:
REMARKS:
DCHD(01-901
EVALUATED BY: H4: &
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 :lay loam, SIL -Silty loam CL -Clay loam SCL-Sandy clay loam
SC -Sandy clay SIC -Silty clay C -Clay
CONSISTENCE
Moist
VFR- V+ --.-y 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
3C --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