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3735 Hwy 158 { w \ V - _ DAVIE COUNTY HEALTH DEPARTMENT 't ,�' do•/o d p�, IMPROVEMENTS PERMIT .AND CERTIFICATE OF COMPLETION ' *N6fE:Issued in Compliance With Article 11 of G.S.Chapter 130a —joyQSanita r Sewage Systems O� Permit Number q„ �..�.. � Name '� .�•��-AA4U, --� Date � � ' '"t No __ - 767u Location 3 � .S. CSW �� \� \UcV\��a •�_�1d�$ '� Subdivision Nara&' Lot No. Sec. or Block No. •`"" ' Lot Size 3 House —.Mobile Home _ Business __ Industry No' Bedrooms ,No.Baths No. in Family Public Assembly Other Garbage Disposal 'YES .0 NOW j Specifications for,System: Auto Dish Washer :YES p NO /Oo a Auto Wash Ma shine YES•EV NO 0 Type Water Supply �o v _ S, *This permit Void if sewage system described belowis not installed within 5 years from date of issue. This permit is subject to revocation if site plans or the intended use change. ` MM y.�•.--i D v K` H• r f 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., 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 ,p -.D t i b 'X Certificate'of Completion Date 'The signing of this certificate shall indicate that the system described above has been installed in compliance�ith s,,-.,.,, 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. � : 0b \ APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERK 1IT •- r Davie County Health Department---------- R EC E WE Environmental Health Section P. O. Box 665 J U L 2 01994 _.. .. ... .. . Mocksville, NC 27028 . - --------------- - 1. Application/Permit Requested By Gr Crac\�S Fay Chas 1 (� l iolmS Mailing Address J� �J5 �"� � g Home Phone 010) 99 - 335 MOCI�SU��P /LJ 7�Da Business Phone (9 10)y1& -Za/0 2. Name on Permit if Different than Above 3. Application for: ❑General Evaluation -- // I-Septic Tank Installation Permit 4. System to Serve: ❑ House �Nlobile 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 a E Nashing Machine No. of Bathrooms ❑ Dishwasher Dwelling Dimensions ❑ Garbage 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 Water Coolers No. of Showers Water Usage Figures 7. Type of water supply: 'F�,KPubIic ❑ Private ❑ Community 8. Property Dimensions 1 7) O aC- Sewage Disposal Contractor 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes [D 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: mss -i � / n�s �' a-h end 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. lam. I 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 he Dg Coun Hal ty[ ment to enter upon above described property located in Davie County and owned by 31 7 - , Inv S to conduct all testing procedures as necessary to determine said site's suitability for a ground absorption sewage treatment and disposal system. DATE SIG A DCHD(1193) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation c' NAME Cs�- DATE EVALUATED p ADDRESS S sa. -t' PROPERTY SIZE PROPOSED FACIILTY �or�A LOCATION OF SITE .� Water Supply: On-Site Well Community Public Evaluation By.<**Ct-- Auger Boring Pit Cut FACTORS 1 2 3 4 Landscape position S .S S S Sloe Z fi_ igo - IV -1 -� %-16— HORIZON I DEPTH J b 1' I?° 21 Texture group L Consistence S F T Structure Mineralogy 1 ',1 HORIZON II DEPTH 4m Texture group C G C., C° Consistence 1P_ F Structure Z.. V_ Cle Mineralogy HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS SS 3 RESTRICTIVE HORIZON — — SAPROLITE S S CLASSIFICATION LONG-TERM ACCEPTANCE RATE ,3 SITE CLASSIFICATION:• EVALUATED BY: LONG-TERM ACCEPTANCE RATE: OTHER(S) PRESENT: iso 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 fine 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 3C-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 DCHD(01-901 ■.tttt.tttttttit..■ttt■■■.■..■■■■■■.■■■■■■■■e■■t.t■tttt.■■tt■.■i�■ ........................... ................... .................. ..■..........................■......................... .......... .........................................:.■....:......■t■.■■.MINN .■ .................................................................. ■.■■■.■.■..■t■■.■■.■■■ttt■■■■■■t■■■■■.■.ttt.■tat.■t.tt.■t.■■■..t■■ ■■■■■■■■■ttt.■■t.t.■■.■■■■ttt■■■■■■.■■t.■t.tt.ttt■:ttstt■.tttt.tt ■■■■■t■■tt■■t..■■■■■.■■aft■t...■■t:..■.■..■■.u.■■..C.■■..■..■..■■ ■■■■■■■H■■■■■■■■■■■■■■■■■■■■■.■�■■■■■...■�.■■■■..t..t■.■..t■ ■■■ ■■t■■■t.s.■■■■■.■t■■■■t■■■■■.■■.■■.■■■e■t■■■■■■■■..■■ ■■■t■■■■■t ■ ■■■t■tttttt■tt■■utt.■■..■tttt■■ttt■tttt■tttt.tt■.tttt.t..t..■.tt ■■■.■t■ttt.t■■t■.tttt■e■■■t.■■■.■■■■.■■..■.a■....■stt.tett�■t■.t..■ ■.■■t..t■t■.■t..ttt..■■tt:::::■.■iii..l'Ti■■..■■.■..■.■■..�..■.■■..t■ ■■■t■■ ■■■■■■ ■■■.■i��l_!w■.rilfil ■■■■tl■M.■■■■■Mt■■t■ ■■■■■■I� ■■■■■■ ■■■■■■ ■■■.■a� s°■t■�I�� : �ta■tl. t.■.tti .ttt■■ t■■t■■ ■■■■■tt■■t■■■■■w��tt��l�l1■■��t/�a.aiu■.t.■t■clt.a�■..t■� t■.■t■..■tt■t■■.■ ■■.■.■■■■■■■■.GI►.i�lC:�J■Int■■.■■■■..■t.■11../�I/■tt■■■■.■..■■..t.■.■■.■ ■■■.t■■.■■■■■I.II■II■.firi��/.t..■■��^==■■■:l.■ I�.r■.■. ■...■tt.■tt■■.t■ ■■■■■■t■■■■■%■I,t.■■■!�! ■■■i:i■/t■■■■.■..tt I/■iim Mm ■ ■■■t.■■t.■■■■■ ..■■■.■■■■.%■t/I■►/■■■r!!Alir/t■..■fl■.■■.■■�■� ■�■■�il1■■1� ■:■.■■■.■■■■■■■■ ::::rA ::%::::::::t\ Ittr1:::::�• ::: :■::� ■.e■�..0=■■■■..� ■t■■■►�e■■a►i■.■►�■►ecita:■■wst!.�,>a■■■■■t■ ■.t u.■■.ir=1,= .■.t■.■u■.�■■■■ ■■..■ryet.t■.r�.r�ttet.t�yt■t_..�===tttr■.t. ■ am EMEMEM ■t .ti ■Nu■■ ■■..■. ■ ■■.■■:l�`\t■.■II■r.!!liltl>f■tl�un■��■tt.11.t./�..■..■■ . ■t■■■■■:■.■■■■ ■ ■.■■■1�ti1�l■■■.■/1i■ri.■■t■.t�.11�1■11.1�.■.�I..■..H ■. �� ■■.■...■■■■.■■.■ ■.■■.■■.11■■fl■Sttt■.■rIl,.►/tl`.,G'�C■`aa..■��..■■■� ■I■. 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All data is compiled from recorded deeds, plats, and other public records and data. Users of this data are hereby notified that the aforementioned public information sources should be consulted for verification of the information.All information contained herein was created for the Davie County's internal use. Davie County, its employees and agents make no warranty as to the correctness or accuracy of the information set forth on this site whether express or Implied, in fact or In law, including without limitation the implied warranties of merchantability and fitness for a particular use. If you have any questions about the data displayed on this website please contact the Davie County Tax Office at(336) 753-6120. 1.5.9 http://maps.daviecountync.gov/itsnettView.aspx?prid=1458290 6/14/2016