573 Ridge Rd- � - - - .. p...y.np).'nY11".•,fy..-.; il`fi"°"iMT19 n1'vfn , .�� -.. .rY ->r a �. � Vin. ,� t. �.�, v....-+,.wN'r.. .._..r .... _
DAVIE 'COUNTY HEALTH DEPARTMENT
_ =T. IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
..--.--.-*NOTE: Issued in Compliance With Article II of G.S. Chapter 130a
Sanitary Sewage Systems �hij�oi- f y� a 7�%2 Permit Number
Name —, Date�-S ��5� N2 7505
Location
t
Lot Size
House
y�
'.Mobile Home _T
No. Bedrooms .No.
Baths
�
i
No. in Family
or Block No.
Business -- Industry
Public Assembly Other
Garbage Disposal YES NO ❑ Specifications for System:
Auto Dish Washer YES NO ❑ �6e4w -s4 "/��T
Auto Wash Ma-hine YES NO ❑ u 'AZ/
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.
[wy
IJ
10-
04
/
U•
� 10(
D
Improvements permit by
-Contact a representative of the Davie County Health Department for final inspection of this systembetween 8:30-9:30 A.M.;
1:00-1:30 P.M. or 4:30-5:00 P.M. on day of completion. Telephone Number: 704-634-5985.
Final Installation Diagram:
System Installed by
G
Certificate' of Completion — _Date T—
'The signing of this certificate shall.indicaie that.the system described above has been installed!in compliance with
the standards set forth in the above regulation, but s`all m NO way be taken as a guarantee that the system will function
satisfactorily for any given period of time.
DAVIE COUNTY HEALTH DEPARTMENT
-' IMPROVEMENTS PERMIT ANDCERTIFICATE OF COMPLETION
tl si--Article 11 of G.S. Chapter 130a —�u—e I n Compliance m p I I a n c e W I t h
.,Sanitary,Sew'age Systems %
e
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section
P. O. Box 665 MAR 21 1994
Mocksville, NC 27028
1. Application/Permit Requested By Q r/LL/A--.- S
Mailing Address 60a DAU/ s ' X n, Home Phone q10 - i<G -,/J93
C7 L EAYA40.vZ _A/,['( �7 t^ /� Business Phone S/d
2. Name on Permit if Different than Above A<ORAIrlA/ cr�5
3. Application for: ❑ General Evaluation J Septic Tank Installation Permit
4. System to Serve: 0/House ❑ Mobile Home ❑ Place of Public Assembly
❑.Business ❑ Industry ❑ Other ❑ Unknown Ti?.4cT
5. If house, mobile home: Subdixvision Z C, A T3Rt�`7 /.VC. Section Lot #
i}/� 730DK (c AIFL perp
z3 asement/Plumbing
No. of People S ❑ Basement/No Plumbing
No. of Bedrooms E Washing Machine
No. of Bathrooms31 S ishwasher
Dwelling Dimensions Pill!; u/2 c'- 4 DVO�9. ,arbage Disposal
6. If business, industry, place of public assembly, other: Specify type �,�
No. of People Served No. of Sinks
No. of Commodes No. of Urinals
No. of Lavatories
No. of Showers
No. of Water Coolers _
Water Usage Figures
7. Type of water supply: 2 Public ❑ Private ❑ Community
8. Property Dimensions ��� Sewage Disposal Contractor ��
9. Do.you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes El No
If ves. what Woe?
'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:
-o c<<, izi�, -;r_0 7)Ar✓/6' 11/ 7-0
ov o�7��s/Tcr s<�c� o<= itP�,owr ftoo�vTz S'qW"'rrcc
J00� pF Fi2ov'7- Gf /)/i2&zr6Lf AC6i2oSS i2/7J4-6 y2» PAOC.cuv
RES/n cF, ;Pt GA 4F C/1 cc / ZALi A.2r09? 9��-766-/3y3
Fr3-�orscc
9P 7A D,46
.�'iti/GC (rC/l-7�Ly- ygc'?s'T `9U0 o/`z %%IG>; Lu/%r-F YDU-fl-I3�rc. 5- f�oc,s�c
C Uta-Tio,v —
This is to certify that the information provided is correct to the
incurred from this application.
3 _ao'- yy
DATE
of my knowledge, and I understand I am responsible for all charges
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 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.
190114
DCHD (1183) .
SIGNATURE
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation.
NAME DATE DATE EVALUATED ��gy
ADDRESS PROPERTY SIZE®QAC/
PROPOSED FACIELTY LOCATION OF SITE
Water. Supply:
Evaluation By:
On-Site Well
Auger Boring
-
11_1� -
Community
.Pit
Public -
- - Cut
FACTORS 1 2 3 1 4
Landscape position
Slope X
HORIZON I DEPTH 17 +! "
Texture group .57 L G G
Consistence
Structure
Mineralogy
HORIZON II DEPTH
Texture group
Consistence I
Structure
Mineralogy
HORIZON III DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
'Texture rou
Consistence
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE
SITE CLASSIFICATION:
LANG -TERM ACCEPTANCE RI
REMARKS:
Landscape Position
EVALUATED BY:
✓ i" /%+
OTHER(S) PRESENT:
LEGEND
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
SBK-Subangular blocky PL -Platy PR -Prismatic
ABK-Angular blocky
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