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177 Georgia Rd ..':_."'-.",.w,n.'.+-�.�s _.'._->.-•�%�_�;:.�x.rrw..�.- �a-r,.:. .t v r—.^-r.,. r , .. ., ->-v >ry.- .......n, .. _..._. ., --. O DAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION *NOTES Issued in Compliance With Article 11 of G.S.Chapter 130a Sanitary Sewage SystemPermit Number `Name *° -„ ate - 7 6 9 4 Location Subdivision Name Lot No.. Sec. or Block No. � t1 Lot Size House — Mobile Home — t Business -- Industry No. Bedrooms �,.f No. Baths _ No. in Family Public Assembly Other Garbage Disposal YES NO ❑ Specifications for System: Auto Dish Washer YES NO let E]Auto Wash Ma thine YES NO E] ` ` /� 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 De art nt 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.T leph 3ne Nu ber:704-634-5985. �r Final Installation Diagram: yste Installed by 0 Certificate of Completion Date S '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. DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation NAME -DATE EVALUATED � y ADDRESS CV PROPERTY SIZE PROPOSED FACIILTY LOCATION OF SITE Water Supply: On-Site Well ✓ Community Public Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3 4 Landscape position .." Slope % HORIZON I DEPTH Texture groupS S S Consistence Structure Mineralogy HORIZON II DEPTH Texture group ' Consistence i Structure Mineralogy .'l HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE k SITE CLASSIFICATION: 1. � EVALUATED BY: LONG-TERM ACCEPTANCE RATE: j 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--Vcry 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 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 ■..■■■■...■.......■/..■..■■■/■...■■....e.■.ee...e■■..ee..■ ISIS■■.e■ ■ISIS......■■....■■■■/.■■e■■■■■.■■ ■■.■....■.■..t■.e■■■■E■EEEE■EE■■ .................................................................. ................................ ............................■EE■ ■■■■■.■....■■■.■..■ISIS.■.......■.ISIS■eIS..■■.■.■..■.■.■■■■■■■■■■t■e■■ ■.■■..■■■.■.■...■.■IS......■e.ISIS...■...■■.■..■EE.E■C■■■■E■■■■■■■■E ■■■.■■■■■E■E■■■■EEE■■.EeE...t.■■■■ ■■■.■■■■.■N■■■.■ ■■■■■■■■■■■■■ ■■■■■■■.■.■■■■.■..■■e.■e.■...IS■■..Mee■■.■■.■.■■■..■■C■■■■■EEE■ E■■ ■■■■■■■N■.■■■■■..■...e.......■. ■■■■■■■■■�■■■■■■■■■■■■■■■■■■�■■■ ■.■■..■.........■.■■■..■.■..■■.. ..■...ISIS■ ■■.a.■e■E■.■■EE■■■...■ ■■.■■■■■.■■■■■.■■■■■■N.■..e.e...ee.■.e........N.e.. ■..ee...■EE ■■..■...■■...■■■ISIS■.■■■■...■■■EE■.■■■■■■■■■■■■■■■■■■■_■■■■■■■■■■ ■� ■.■■■■■■■■.■..■■..■■.■..■■■■.t�.N..■.■■e■t■yawn■.E.■■■■■■■E■eEE■■ ■.■■■■■■■.■■..■■■■■.■■►�■.Me■■.■e■■.■...■e...■.■.■■/ ..lJ ISIS...■■ ■■■..■..■.■.■■te..■■/�■■■e■■.■.■■■■ISIS■■■S■■■■■■■■■■■CMEMGREMEME■■■ ■...■■■■.■■■■■tE■■E■■■■■ME■■■■■�O�■��..■■■■■■■.■■■■■■■eE■N■■■■■■.■■ ■..e■■....■.e■■e...■e.IS.■■■I..■■..e..■.■■.■e■■■/■■■■■■■■■■ ISIS.■■.■■ ■■■■.■■■■■■■■■■■■■■■■■.■■■■I■■■■■■.■■.■M■ ISIS■■■■■ ■■■■.■.�■..■■..■ ■■■.■■■■■■■■■■.■■■■■e.■..e■I■�..��J. .ISIS■.■ ■ ■■■■■■■■■■.■.■ ....................... ■■...e.r: ME.. ..■. N t■ ■ ■■ ■M■■■■ CCCCCCCCC:C�:::::::::::::::::::: :::■ SEEN � MMOMMMOM CCCCCCn ■■■■■■■■■■■■■■■■■■.■■■■■■■■■■■E■E■M■■. CML■ ■IS■■.■IS.■■■■.■■■■■.■.■■■..■■■■M■■■M■..■■e■■■E■■■■■■■■■.■.■■e.■■■■■■■■■■■M■■■■■.■E■■■E■.■n■■r.n■E■■■■.■■E■■■■■■■E■■■■..E■.■■■■■■..E■■.e■■■.0_C.■..C■.'u■■■■■■.C.EC .=■■■■'C■■=i.■■ ■■■N■. E■■■■E ■ ■_ E■E■E■E ■■■■E■ MON ■■CC ' C■ISMO■ ■ S■ H■ Ce�C C■ ■O■ ■' ■■■■■■E■ ■■..■■■■■■■■■■■■■1'�fiY■■■■■■■■■■■ ISIS■.■ROME M ISIS■■ ISIS.■.e■■e■■■..■.■ MMM ::::::: '■=CCCCCCCCCCCCCCC::::::::' ■:"CCCCCCuiiiCCCC CCCCCCCC:CCCCCCCCCCCCCCCCCCCCCCCCCCCC.'C WCCCCCCCCCCCCmo MMMMMMMM■■ .■....e■..e..e...e...../..e....■ ■e./ISIS..■..■.N.■.■e.e■.■...e■.■ .........eNe■■......■e.IS■IS.e.■..■■■e...■ ISIS■■■NE■e■..■■■■■t.■■■■ ■.■■■■■■■■■■■■■■......■■■EN.e■■.■e..■.e.■�=ht /...ISIS■■. ■....ISIS\ MM ■.ISIS.■■N■e■■■ISISIS■.ISIS■..■ ..........■He. CC■■■..■■e■Ce■N.eIS. .........■...................... ■■M■■■■■IS■■■■MOM■■M■■EM■■■.■■.■■ .................NIS....IS■.IS■N..■E.■■=..■■■■■■■■■Et■■■■eNE■EM■■■ .................................................................. ■■.■ ■■■■■EE■■..■IS.■■.■■■IS■■■■e.■.■E.e■■.■.E■e.■■E■■E■■■■E■■■■MEMO ■.■■ ■■.e.■N..■■■■■.■..ISIS..■..■�.■./.....■....■.■.■IS■ISIS■■■■.■■.■ ■...■■■..■■■■■.■■e.IS■IS.e.■■EIS.ISUIS■■eISIS..IS■■■■e.IS■■.eISe.M■■..■...■ APPLICATION FOR SITE EVALUATION/IMPROVEMENTS P Davie County Health Department EC E I�7 E D Environmental Health Section 11994 1 P. O. Box 665 AUG Mocksville, NC 27028 --------------- 1. Application/Permit Requested By Z066i Mailing Address �Ihi/n 10Rn CT Home Phone lL nZ44 t/5 i✓C. o?7fl/,2 Business Phone 2. Name on Permit if Different than Above 3. Application for: a General Evaluation lySeptic Tank Installation Permit 4. System to Serve: R House ❑ Mobile Home ❑ Place of Public Assembly ❑ Business ❑ Industry ❑ Other ❑ Unknown 5. If house, mobile home: Subdivision Section Lot # C'Basement/Plumbing No. of People ❑ Basement/No Plumbing No. of Bedrooms -3 D-Washing Machine No. of Bathrooms C-Dishwasher Dwelling Dimensions ,2.4 'X 4¢ p-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 R-Private ❑ Community 8. Property Dimensions At Sewage Disposal Contractor 4111% Aid 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: !o�fGU- %� - '��%�le0 eeV- 7-Al 0 ,&iu Me(,//�i•v�/��- i �,� ew 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 applicati4ex o /I 21. DATE SI NA URE CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY Fanddisposal ECK ONE: ❑ 1. 1 OWN the property. kJ 2. 1 DO NOT OWN the property. ked Box #2, the rest of this form MUST be completed by the owner or a person authorized by the owner: ve consent to the authorized representative f the D ou ,,Walt j[hep rtment to enter upon above described cated in Davie County and owned by {-/ JC all testing procedures as necessary to determin said ite's i b''ty f r a ground absorption sewage treatment al system. e DATE SIGNATURE DCHD(1193)