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k' DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTE: Issued in Compliance With Article II of G.S. Chapter 130a
aru a se �>e S/JtJ ms � .N�l -�,, ,�yr11 �D -; �'-�%'� Permit,,H�er
Date NO
Name v�` �Q /-� < ,%Ol"s ,(;FJ- .fir �- r' % `✓ /`� � -�/C ,; , , �. � � .
Location e- _ �n
S /� F `Y r/ Y a✓'%i�/ ,/_)Gi✓: /r c.•%— — l :`r.s-.� / - /c• —7
Subdivision Name Lot No. Sec. or Block No.
/// C 1/
Lot Size House— Mobile Home Business __ Speculation
No. Bedrooms No. Baths No. in Family _
Garbage Disposal YES ❑ NO 6
S
Auto Dish Washer YES NO ❑ j cifigaioras.,fgES�cstem:
Auto Wash Ma shine YES j NO ❑"�X
Type Water Supply __—
*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.
(� ttlw r
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:
System Installed by
Certificate of Completion �% L� 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.
� I^
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMI���®
Davie County Health Department R E `'"
Environmental Health Section OCA _ 2 1992
P. O. Box 665
Mocksville, NC 27028 _ _ _ -----
1.
____1. Application/Permit Requested ByfJ\ 4
Mailing Address –2C /J D ` e (� LIA C e ID-% UD (12Home Phone _ _ 912 '-92 Z— -V Business Phone
2. Name on Permit if Different than Above
3. Application/Permit for: ❑ General Evaluation E9 Septic Tank Installation
4. System to Serve: ❑ House 29 Mobile Home ❑ Place of Public Assembly
❑ Business ❑ Industry ❑ Other ❑ Unknown
5. If house, mobile home: Subdivision Section Lot #
❑ Basement/Plumbing
No. of People �--- ❑ Basement/No Plumbing
No. of Bedrooms 19 Washing Machine
No. of Bathrooms ❑ Dishwasher
Dwelling Dimensions X ( _S ❑ Garbage Disposal
6. If business, industry, place of public assembly, other: Specify type
No. of People Served
No. of Commodes
No. of Lavatories
No. of Showers
7. Type of water supply: ❑ Public
No. of Sinks
No. of Urinals
No. of Water Coolers
Water Usage Figures
® Private
8. Property Dimensions % a-6� Sewage Disposal Contractor
9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes
If yes, what type?
❑No7,
❑ 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:_p �t /���/I 6 5�
��-q�sZ
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: � 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 representat/if the Davie unty 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.
/o 9,- 4�F
DATE SIGNATURE
DCHD (12-90)
DAVIE COUNTY HEAL—PH DEPARTMENT
Environmental Health Section
Soil/Site - Eyaluation
NAME ��/�JJ �Y)✓ DATE EVALUATED ZZ - 4;,'-2-
ADDRESS
;,'2ADDRESS PROPERTY SIZE
PROPOSED FACIILTY �C�,rY LOCATION OF SITE 557
Water Supply:
On -Site Well Ll
Community
Public
Evaluation By:
Auger Boring 4i
Pit
Cut
Sloe %. —
-
-
—
FACTORS 1
2
3
4
Landscape position
Sloe %. —
-
-
—
HORIZON I DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH�-
Texturegroup
�-
C_
C
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
L
SITE CLASSIFICATION:
LONG-TERM ACCEPTANCE RATE:
REMARKS:
DCHD(01-901
'EVALUATED BY:
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
Tevtwe
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/(t2