652 Hwy 801S (2)DAVIE COUNTY HEALTH DEPARTMENT
`= 4 IMPROVEMENTS PERMIT AND . CERTIFICATE OF COMPLETION
*NOTE:'Issued in Compliance With Article 11 of G.S. Chapter 130a Z2o a%
Sanitary Sewage Systems Permit Number
Named!' a�Kii�P.ry�'� ��G'ti"��/lg��✓ Date NO
Location X5 K "
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Subdivision Name Lot No. Sec. or Block No.
Lot Size % House 41111' a Mobile Home _� Business Speculation
No. Bedrooms / No. Baths _�_ No. in Family _
Garbage Disposal YES ❑ NO Specifications for System:
Auto Dish Washer. YES ❑ NO
Auto Wash Ma :hiveYES ❑ NO [P �dD�✓% `r� X 2 `�
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.
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 Insta led by
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Certificate of Completion 1l 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
satisfactorilv for anv aiven period of time..
7F
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT _
Davie County Health Department j' �. i; i;s" !« V:
Environmental Health Section>.
P. O. Box 665
Mocksville, NC 27028
std By
Mailing Address Z '' U. -4-)d�/d X /6 X lfVcJ79
C�--
Home Phone 7'2 �JE ,�,0 0:2, Business Phone.
2. Name on Permit if Different than Above
3. Application/Permit for: ❑ General Evaluation
4. System to Serve: ❑ House ❑ Mobile Home
JR Business ❑ Industry ❑ Other
5. If house, mobile home: Subdivision
No. of People
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 Sinks _
No. of Urinals
No. of Water Coolers
Septic Tank Installation
❑ 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: J$1 Public ❑ Private /J 1 ❑ Community
8. Property Dimensions s Sewage Disposal Contractor
9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes Jgl 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:
e -' 'O5.5 ipai �/
0/,7 3s �'I
This is to certify that the information provided is correct to the best of my
incurred from this application.
DATE
SIG
I understand I am responsible for all charges
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 f erm 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.
Z,
DATE SfGNATURE
DCHD (12-90)
i
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
NAME A, J L�L�yG'--,
ADDRESS
PROPOSED FACIILTY
DATE EVALUATED ,--Z' %
PROPERTY SIZE
LOCATION OF SITE VIII
Water Supply: On -Site Well Community Public -L-1
Evaluation By: Auger Boring r,-,' Pit Cut
FACTORS 1
2 3
4
Landscape position A.
E. 4
L
Sloe Z =—
—
—
HORIZON I DEPTH
Texture group
Consistence
Structure
MineralogX
HORIZON II DEPTH
Texture group
Consistence 411
Structure r
siji� ii
6/C
Mineralogy
- /
HORIZON III DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
J
LONG-TERM ACCEPTANCE RATE ,
SITE CLASSIFICATION:
LONG-TERM ACCEPTANCE RATE:
REMARKS:
DCHD(01-901
EVALUATED BY: A/0
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 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
Mineralolly
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
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