659 Hwy 801Ni�fV ': ^'� 'r Y�`.�; vf<...���'iF e� 'Y`r i'�AL '? id �,(t.�. SLS.. .-,ti'w`ud a,!{,r �:a Vi .;,i:t .J'"'ii �G' .ra.d�r--� I'✓'a,r,s�'`.iv.,„ 7 7�`" -�'.�
�`- DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
NOTE Issued in Compliance With Article I I of G.S. Chapter 130a ` __
Sanry 'taewage Syst ms , Z� °° Permit Number
Name Date
mo 7137
Location
Subdivision Name
Lot No. Sec. or Block No.
Lot Size
House T
7No.
Mobile Home __ Business __
Speculation
No. Bedrooms
.No. Baths
in Family _
Garbage Disposal
YES PNO ❑
Sp cificatiol►s> for
`�
Auto Dish Washer
YES NO ❑
/%%�/r'�
Auto Wash Ma thine
YES., ❑ NO ❑
v
Type Water Supply
__—
'This permit Void if sewage system described below is not installed within 5 years from date of issue.
This permit is s bject to revocation if site plans or the intended use change.
�eli 1 A�
. .. . .............................. .
Improvements permit by
/Z"
"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:
System Installed by
Completion Date el,1
11_�e_
Certificate of Com p—
'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/IMPROVEMENTSr
Davie County Health Department D
Environmental Health Section
P. O. Box 665
Mocksville, NC 27028 j ^(
1. Application/Permit Requested By --� Y
Mailing Address Q' ` Q O k
Home Phone q9 2' r -:;(ca (o
2. Name on Permit if Different than Above
3. Application/Permit for:
4. System to Serve: House
❑ Business ❑ Industry
5. If house, mobile home: Subdivision
�c� [E 0W[E
lyJ'AY7141111J)9-J3
S1v . �--
Business Phone 113 ' 2 t0
A(2t N,e. I i
❑ General Evaluation
❑ Mobile Home
❑ Other
No. of People
No. of Bedrooms 2—
No.
No. of Bathrooms ?—
Dwelling
Dwelling Dimensions ?r R kkAp
6. If business, industry, place of public assembly, other: Specify type
No. of People Served
No. of Commodes
No. of Sinks _
No. of Urinals
No. of Lavatories No. of Water Coolers.
No. of Showers Water Usage Figures
7. Type of water supply: Public ❑ Private
8. Property Dimensions X00' X Sewage Disposal Contractoi
9. Do you anticipate additions/expansion of the facility this sytem is intended to serve?
If vPs_ what tvnP?
,Septic Tank Installation
❑ Place of Public Assembly
❑ Unknown
Section Lot #
❑ Basement/Plumbing
'AfBasement/No Plumbing
Washing Machine
J Dishwasher
Garbage Disposal
❑ Yes (�/N0
❑ 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: tf) AST TM Fo l �,Q:TA - -D -e j I ,RISS S Tt2e c 7
N7-
This
T
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 fr m t is application.
_ M�9�
DATE SIGNATURE
CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY
MUST CHECK ONE: ❑ 1. 1 OWN the property. W 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
tz 17
property located in Davie County and owned by aIRP 055
to conduct all testing procedures as necessary to determine said site's suitability for a ground absorption sewage treatment
and disposal system.
g3
DATE SIGNATURE
DCHD (12-90)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
/-5 IMF pi
I
ADDRESS
PROPOSED FACIILTY *'Ve--Sel
DATE EVALUATED
PROPERTY SIZE /"Grz2s
LOCATION OF SITE
Water Supply: On -Site Well Community Public
Evaluation By: Auger Boring f Pit Cut
FACTORS 1 2
3
4
Landscape position
Sloe % ---
--
HORIZON I DEPTH
Texture group
Consistence
Structure
Mineralogy 1
HORIZON II DEPTH
t"elp
-+-
Texture group
G
Consistence
Structure
b /C
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: _ /) EVALUATED BY: ZZ
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
CONSISTENCE
Moist
VFR-Very friable FR -Friable FI -Firm VFI-Very firm EFI-Extremely
Wet
NS -Non sticky SS -Slightly sticky S -Sticky VS -Very Sticky
NP -Non plastic SP -Slightly plastic P -Plastic VP -Very p18' -
Structure
SC -Single grain M -Massive CR -Crumb GR-Granu!
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 surfbl
Saprolite - S(suitable), U(unsuitable)
Soil wetness - Inches from land surface to free water, or inti.
with chroma 2 or less
Classification - S(suitable), PS(provisionally suitable), U(unsuitabl.
LTAR - Long-term acceptance rate - gal/day/ft2
DCHD(01-901
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