2252 Hwy 801SDAVIE COUNTY HEALTH DEPARTMENT o 0
IMPROVEMENTS PERMIT AND, CERTIFICATE -OF COMPLETION
'*NOTE:Jssued in Compliance With Article 11 of G.S. Chapter 130a
Sanitary Sewage Systems Permit Number
Name Date NO
6580
Location
V\ '25 U
_E Subdivision Nama L61 No. Sec. or Block No.
Lot Size' s House Mobile Home Business Speculation
r\
No. Bedrooms No. Baths No. in Family
Garbage Disposal YES [E/ NO ❑, Specifications for System:
Auto Dish Washer., YES' NO C,
Auto Wash Ma-.hine YES [� NO E]
Type Water Supply c, v 6-`K,��/
I
*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.
Vo vtx,
Improvements permit by
County He
alt a representative of the Davee0C lealt artment for final inspection of this system between 8:30-
_ apartment
9:30 A.M. or 1:00-1:30 P.M. on d f completion. Talephone Number 704-634-5985.
Final Installation Diagram: (I �System Installed by
Certificate of Completion Date x k
'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.
PLO
r APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT, ,\ OCT 2 81991
k h ► Davie County Health Department
.Y w —41991
Environmental Health Section%
(_ P. O. Box 665
Mocksville, NC 27028
1. Application/Permit Requested By
Mailing Address
Home Phone 2/9- 21.x— l --5;-9,e Business Phone g/%"
2. Name on Permit if Different than Above
3. Application/Permit for: ❑ General Evaluation
4. System to Serve:ouse O -A -B'fulobile Home
❑ Business ❑ Industry ❑ Other
5. If house, mobile home: Subdivision
No. of People
No. of Bedrooms 13
No. of Bathrooms _ _ 2 /
Dwelling Dimensions /860 e5Q >Z
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
III -VA
eptic Tank Installation
❑ Place of Public Assembly
❑ Unknown
Section Lot #
❑ Basement/Plumbing
❑ Basement/No Plumbing
2 -Washing Machine
GJ-dshwasher
garbage Disposal
7. Type of water supply: 93"Public ( ❑ Private��11 ommunity
0
8. Property Dimensions Accas Sewage Disposal Contractor �A-J' le /vim 6) cwA Ze� 12-
9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes Aa -9 -0 --
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: =S S M c% c r✓
Cc"C� Com_ `'�v�,
v
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: ®0<I OWN the property. ❑ 2. 1 DO NOT OWN the property.
If you checked Box #2, the rest of this form MUST be com tete y the owner or a person authorized by the owner:
I hereby give consent to the authorized representati rre C9un t to enter above described
property located in Davie County and owned by
to conduct all testing procedures as necessary to determine said a te's suitabili for r n absorption sewage treatment
and disposal sys em. /
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1.
X S.. --?,Z - -.,n -1 4 , - , I - - - , .4 --* & —Q
DAT SI URE
DCHD (12-90)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
NAME
ADDRESS Sa
PROPOSED FACIILTY \A rn oa \L
Water Supply: On -Site Well
DATE EVALUATED
PROPERTY SIZE
LOCATION OF SITE 1961-S
Community
Public V
Evaluation By:�—'�,V Auger Boring ✓ Pit Cut
FACTORS
1
2
3
4
Landscape position
S"
3
-5
Sloe %
7 -IS
S -►s
`d �IS
HORIZON I DEPTH
/�."
Texture group
Sc L
S c�
c: t-.
S c L
Consistence
-R
FR6z
�k2
Structure
CQ R
2
(_1 R
Mineralogy
1.1
1 1
7
;l
HORIZON II DEPTH
Texture group
S C
v C
S
S c
Consistence
-�
�.
_ !Z
FR
Structure
Mineralogy
i11
I t
I
HORIZON III DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
—
-
-
-
SAPROLITE
CLASSIFICATION
S
S
LONG-TERM ACCEPTANCE RATE
3b
SITE CLASSIFICATION: � _ EVALUATED BY:
LONG-TERM ACCEPTANCE RATE:
�S OTHER(S) PRESENT: N o ti9
REMARKS: V-411.1 S X�. � .� a Is", z- - �) � mow, 3I1 n __\01
DCHD(01-901
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 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.