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443 Angell Rd t. r,rf A >�... o-a r q ., i, t ,�; A"'Y R:• 1 LJ'�«� 5�s -..rwA Y`t'Ea a +..�wiA" ,t Jq:.,4ik �7i°i�'+*p��fy�• ��; t' a"f'44, .�,.. �R ,� � ,r'w `�;-..e�w r- .ii. 's s;�,»_;.� a f*��,•, ",..:;.;. � DAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION *NOTE:Issued in Compliance With Article II of G.S.Chapter 130a Y %Sanita •f �ewa a Sys e s r r s /�. Permit Number �,cs� �? s' Name / Date _ /iN0 7171 L �� � ✓ l" �:✓ lri'l�Ysvilr!'/� l/G-f.T � �v Loca`ti n � — �/ �J./ l f"//r ��✓ /l""•F :` ,i��i�s" �' J Gif.� dam— Subdivision Name Lot No. Sec. or Block No. Lot Size%fJ House Mobile Home Business Speculation 17 No. Bedrooms :: .No. Baths No. in Family-- Garbage amily _Garbage Disposal YES NO ❑ Specjfications ,,d�or System: Auto Dish Washer YES NO ❑ /GLG ��/ +°R Auto Wash Ma:hive YES ❑ NO ❑ l� ,r/�' .�_'J ��«' 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. 1= 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 Installed by �(//�` T— 1= 11 Certificate of Completion 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 satisfactorily for any given period of time. APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT / r�1tl Davie County Health Department� e S� �/e& )1r Environmental Health Section RE E h�t� ryt "I►� P. O. Box 665 /l I Mocksville, NC 27028 MAY 03 1. Application/Permit Requested By. Mailing Addressl1� V QI�Q Cc- . 70 31� Home Phone :11�'s3a l Business Phone 2. Name on Permit if Different than Above 3. Application/Permit for: ❑ General Evaluation Vseptic Tank Installation 4. System to Serve: ❑ House "obile 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 ❑ Washing Machine No. of Bathrooms ❑ Dishwasher Dwelling Dimensions x ❑ 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 U?Arivate ❑ Community 8. Property Dimensions o Sewage Disposal Contractor 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes No `7 & 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: o n mac, ; n G h . Rd . - -1�t ©It q (n(2�, l 7R d . -t- Oil b3c�od wc, CcoSS / `qO . }R-. 0R noJQ, Q-:�i pgsA- Z,3 h.ouS o f1 "�f. 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 his application. DATE SIGNATURE CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY MUST CHECK ONE: ,g(1. I OWN the property. ❑ 2. 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 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. DATE SIGNATURE DCHD(12-90) DAV'IE COUNTY HEALTH DEPARTMENT q , IMPROVEMENTS PERMIT AND .CERTIFICATE OF COMPLETION y*NOTE:Issued in Compliance With Article II of G.S.Chapter 130a - - Sanitary Sewage Systems) -, Permit Number Name %e'cDate N_2 FF 3 Location `%'"/,�5�� Al i Subdivision Name Lot No. Sec..or Block No. Lot Size House Ate/ Mobile Home Business __ Speculation No. Bedrooms. No. Baths-- No. in Family Garbage Disposal YES ❑ NO 0-' Sp/ecifications for System: Auto Dish Washer. YES NO ❑ ;f. . ; l Auto Wash Ma.hine YES NO ❑ �`` Type Water Supply *This,permit Void if sewage system described below is not installed within 5 ears from date of issue. Thisrpermit is subject to revocation if site plans or the i tended use change. ff 14f J� ( Improvements permit by *Contact a representative o the D vie County Health Department for final inspection of this system between 8:30- 9:30 A.M. or 1:00-1:30 P.M. on d y of completion. Telephone Number 704-634-5985. Final Installation Diagram: System Installed by f , Certificate of Completion 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 satisfactorily for any given period of time. APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT r , Davie County Health Department w �i. Environmental Health Section �� . . P. 0. Box 665 PELF- NM Mocksville, NC 27028 1 . Application/Permit Requested By M iling Address Zl-)A/- 36 14- 1;�61d K5 o/-1/e : 30 /mme Phone Business Phone L/' X07' 2. Name on Permit if Different than Above 3. Property Owner if Different than Above 4. Application/Permit For: C) General Evaluation VS/Tank Installation 5. System to Serve: House 3140bile Home 0 Business LL Industry u Other 0 Unknown 6. If house, mobile home: Subdivision Sec. Lot# No. of People --I Dwelling Dimensions No. of Bedrooms Basement/Plumbing No of Bathrooms Basement/No Plumbing 6;lwashing Machine 0 Dishwasher C) Garbage Dispusai 7. If business, industry, 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 8. Type of water supply: 0 Public vprivate 0 Community 9. Property Dimensions ea-aIL" 10. Sewage Disposal Contractor 11 . Do you anticipate additions/expansions of the facility this system isintended to serve? 0 Yes o 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. 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 Directions to Property : f� /� o P Ao h oo rM;n hwrC LQ t� d K )00 3 'a C''Gc�Se O "Cie l �1171 2 DCHD (10-89) DAVIE COUNTY HEALTH DEPARTMENT ENVIRONMENTAL HEALTH SECTION SITE EVALUATION CONSENT FORM 1. Complete the form below and return to the Davie County Health Department. 2. Carefully follow the procedures as outlined in the enclosed "Information Bulletin." NOTE: THE ABOVE MUST BE COMPLETED BEFORE A SANITARIAN WILL BE ABLE TO BEGIN THE REQUESTED EVALUATION. DETACH HERE AND RETURN TO: Davie County Health Department, Environmental Health Section, P. O. Box 665, Mocksville, N.C. 27028 Davie County Health Department Environmental Health Section Site Evaluation Consent Form LOCATION OF PROPERTY: DATE RECEIVED (office use only) yes no 1. 1 am the owner of the above described property. yes no 2. 1 am not the owner of the above described property, however, I certify that I have consent from 9/e0Qdat ,�C��Q�7ro�'k , owner to obtain a owner's name site evaluation by the Davie County Health Department for the purpose of determining the suitability for a ground absorption sewage treatment and disposal system. yes no 3. 1 hereby give consent to the authorized representative of the Davie County Health Departmentto enter upon the above described property and conduct all testing procedures as necessary to determine its suitability for a ground absorption sewage treatment and disposal system. D" ATE SIGNATURE 4. 1 hereby authorize the Davie County Health Department to release site evaluation results from the above described property to the following: — Owner only Owners designated representative Anyone requesting results Only those listed below rA,_ DATE SIGNATURE DCHD(11/84) ' DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation NAME �m�/1 S DATE EVALUATED ADDRESS PROPERTY SIZE PROPOSED FACIILTY LOCATION OF SITE Water Supply: On-Site Well Community Public t� Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3 4 Landscape position L .0 Slope % HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH d Texture group Consistence Structure 771 Mineralogy HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION S. R S_ LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: i EVALUATED BY: �Aa 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 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 DCHD(01-901 ■■■■■■■n■■■■.■■■■■■■.■■■■■■■■■■ ■..■■■..■...■..........■....�■■■ .................................................................. ................................ ................................ l::::::"EMME:: :C:C:: MEMNON�lo:::::S3::::: l:::::: ! ■..■■■■■.■■■.■■■■■■■■..■.-============—■■.■.■■■......■.■.......■■ ::':::::::C:EMNON 0 ....e................................................... ........ ................................ .............. ................. e..■■■■M■..C..................................................... ................................ ...........................�.■■■ ................................ ................................ ......................................................... ........ ■......M■...........■■■■.........■.......■..............�■■..■■.. iiiiiiiiiiiiiiiiiiii�■'iiiiiiiiiii�iiiii�iiiiiii�i'.iiieii�iiiiiii iiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiu■iiiiiiiiiiiiiiiiiiiiiiiiiiiiiiii