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229 Grady Ln _ DAVIE COUNTY HEALTH DEPARTMENT:.' l C�c3`. 06 IMPROVEMENTS PERMIT AND !CERTIFICATE,OF COMPLETION NE:Issued in Com 6t1` pliance With Article I I of G.S.Chapter 130a Sanitary,Sewage Systems Permif Number Name �`s; �'� .. _�_' Date to ,, ' � N� 8 �j'9 Location a, 4- ,c Subdivision Name Lot No. ec. or Block No. Lot Size _ House Mobile Home ____ Business —_ Industry No. Bedrooms No. Baths _ � No. in Family Public Assembly Other Garbage Disposal YES [0/ NO ❑ Specifications. for System: Auto Dish Washer YES 6 NO ❑ �j _ , Auto Wash Ma':hine YES e .'NO ❑ 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 ATTENTION: YOUR SEPTIC SYSTEM CONTRACTOR MUST SEE THIS PERMIT/LAYOUT BEFORE INSTALLING THIS SYSTEM. C3 �? ` �A F 4 it.; '. . ' 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: f System Installed by 0 V Certificate o orn tion Date 'The signing of this certificate shatrindicate the sy em de ribed above hasbeeninstalled in compliance with v,"the standards set forth in the abov ion, but s in.N�� ay betaken as a guarantee that the system will function satisfactorily for any given period of time, i� a RR M APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PER U U Davie County Health Department _ 9 Environmental Health Section AIN IM P. O. Box 665 Mocksville, NC 27028 EUVIR0fU"TE-UTAtN DAVIE UI4IITY 1. Application/Permit Requested Mailing Address ZZ Q`Le Home Phone q6L 7`18 "Zy?�-s' /VC Business Phone IV O 2. Name on Permit if Different than Above 3. Application for: General Evaluation ❑Septic Tank Installation Permit 4. System to Serve: ouse ❑ Mobile Home ❑ Place of Public Assembly ❑ Business ❑ Industry ❑ Other ❑ Unknown 5. If house, mobile home: Subdivision Section Lot # ❑ Basement/Plumbing No. of People 2-1asement/No Plumbing No. of Bedrooms 2-Washing Machine No. of Bathrooms -3Dishwasher Dwelling Dimensions 4y X Z(e 2 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: ❑ Public Private ❑ Community 8. Property Dimensions z Sewage Disposal Contractor 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes 2-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:DO-J 0"-5>-4-ozLe/-S / �'fGt'�Q•��- ��Lh-�.e:� ��j'G G o-,u.•G. � �Q.tJ!G P�-4�,��t�, �Qy� � , X70-% 45 lie This is to certify that the information provided i orrect to the best of my know ge, and I understand I am responsible for all charges incurred from this ap lic n. 1-7 DATE SIGNATURE CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY MUST CHECK ONE: ❑ 1. 1 OWN the property. B-�'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 representativ of the Davie County H Ith �}epartment to enter upon above described property located in Davie County and owned by�LZ..J rt. Lc t W. �� to conduct all testing procedures as necessary to determine said site's suitability for a ground absorption sewage treatment and disposal system. S ATE SIGNATURE DCHD(1193) ' DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation NAME �^�N Q"(Z�to Q DATE EVALUATED ADDRESS S Q-fj* PROPERTY SIZE PROPOSED FACIILTY `A 0 g LOCATION OF SITE Water Supply: On-Site Well _ Community Public Evaluation By:IZ"�t(,Auger Boring Pit Cut FACTORS 1 1 2 3 4 Landscape position Sloe % " 50 ° `6 )5 HORIZON I DEPTH 10 Texture group 1_ 1-- Consistence Y Structure MineralogX HORIZON II DEPTH 1 Texture groupC t Consistence s F Structure B\� Mineralogy HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS s s' RESTRICTIVE HORIZON SAPROLITE �- CLASSIFICATION �•S ,S LONG-TERM ACCEPTANCE RATE kA 4 SITE CLASSIFICATION: S' EVALUATED BY: LONG-TERM ACCEPTANCE RATE: OTHER(S) PRESENT: 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 -;lay loam- SIL-Silty loam CL-Clay loam SCL-Sandy clay loam SC-Sandy clay SIC-Silty clay C-Clay CONSISTENCE Moist VFR-Vc.-y 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 .;C--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 ■.■.■..■■■■■..■■■.■..■..■■■..■■.■■■■■■.■■■..■.■.■.■■.■.■.■ .C!■.�■ ■■.■.■.■..■..■....■..■■...■...■.■■.■■■■.■.■ ■■.■■■■■ IN■■■IN■■■■■E■■ ................................■.........C...■■...�..■..■■■...■. ■.■.■■■■■..■■■...■■■■....■■...■■ ME■MMM■■ EMEMM.M■ ■■MMEME■E■■■■■ ■■■■■■■■■■■■■■■■■.■■■■■■.■■S■■■■■■■■■■■■■■■■■■■S■■■ESM■■■SMEMM■MM■ ■■■■■■.■■■■■■■■■■■■■■■■■■■■■■■■■A■.■■■■■�■■■S ■S1SONO S■MEMME■I ■■■■■.■■■...■■■■..■■.■■■■■■.■■■.■�■■■■■■■■.■■■■.■ ■■■■■■ ■■■■■■■■■ ■■■..■....■.■■...■.■....■.■.■■■■ 1■M.■■■■■■■.■.■■■■■IN■INS■■.■■■■■■ ■.■■■■....■■■.■■■■■■■.■■.��■■■■.■■■■►■.■M■■■IN■■S■S=■■M■■■■■■■■M■■■ ■■■■■■■■■■.■.■■■■■■■■■.■■■\\...■■■■. \N.■..■■■.■■ ■■■■■ M■ME■■■■ ■■■■■■■■■■.■■.■■■■►■■■.■■■■■►■■■■■ ■■MI•■■■■■ENM■■.■CINM■■■ .■�■■ ■ ■■.....■■.■.■■■■..■►�.■■.■■.■�■■■■■■..■►�■■■.■ ..■■■■ ■■.■..■■ ■M. 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