P6498 Hwy 64WG '
DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTE: Issued in Compliance With Article I I of G.S. Chapter 130a j
iSanitary Sewage Systems) �� , } Permit Number
Name l !7`� 7(�.r9rrl7flY.i?'�d��%1� Date E/ N2 .640/8 8
Subdivision Named Lot No. Sec. or Block No.
Lot Size A HSC House _z Mobile Home Business Speculation
No. Bedrooms No. Baths :�7 No. in Family
—
Garbage Disposal YES ❑ NO p- Specifications for System:
Auto Dish Washer. YES NO
Auto Wash Ma^hine YES NO ❑
1-2
Type Water Supply - /,1��� --- a, = G�il�� 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 —e
*Contact a representative of the Davie County Health Department for final inspeciion=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 <�b
Certificate of Completion _r /�� 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.
T
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1. Application/Perm
Mailing Address
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section
P. O. Box 665
Mocksville, NC 27028 boo M
Home Phone Ty 9" h 7 (n A Business Phone
2. Name on Permit if Different than Above
3. Application/Permit for: ❑ General Evaluation
4. System to Serve: m House ❑ Mobile Home
❑ Business D Industry ❑ Other
5. If house, mobile home: Subdivision
No. of People (x
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 Showers
No. of Sinks
No. of Urinals
No. of Water Coolers
Water Usage Figures
® Septic Tank Installation
❑ Place of Public Assembly
❑ Unknown
Section Lot #
® Basement/Plumbing
❑ Basement/No Plumbing
Washing Machine
❑ Dishwasher
❑ Garbage Disposal
7. Type of water supply: ❑ Public V3 Private ❑ ommunity
8. Property Dimensions 13
) 0C+ res Sewage Disposal Contractor &b 5 rnC
9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? D Yes ® 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:`17
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0//7 6) 4 T / " �C (Ov-\ �,e
0-((Cen,5-6,6"kc� w h l c�q h ct
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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 responsible for all charges
incurred from this application. �
DATE SIGNATURE
CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY
MUST CHECK ONE: J9 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
and disposal system.
DATE SIGNATURE
DCHD (12-90)
.w
.�_ DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
NAME �Cf%✓!%
ADDRESS
PROPOSED FACIILTY �&
DATE EVALUATED O %/
PROPERTY SIZE el-fXe-
LOCATION OF SITE 6JW
Water Supply:
On -Site Well
Community
Public
Evaluation By:
Auger Boring
Pit
Cut
FACTORS 1
2 3 4
Landscape position 4L
J_ L
Sloe %
HORIZON I DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH
Texture groupC'
G'
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: %S _ EVALUATED BY: d /X�t
LONG-TERM ACCEPTANCE RATE: ,� 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
Moist
VFR-Very friable FR -Friable FI -Finn 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
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