166 Green Grass Rd (2) Davie County Health Department
Pig t Environmental Health Section t . ,
P.O. Box 848
210 Hospital Street
p Courier# : 09-40-06 =c
Mocksville, NC 27028
Phone:(336)-753-6780 Fax:(336)-753-1680
ON-SITE WASTEWATER CERTIFICATION
(Check One) Replacement Remodeling Reconnection
Name: t e�aGl u�Lia ��''`r�� Phone Number 6, Z�'YSOG (Home)
Mailing Address: fi « COPA' ' ' (Work)
ti, 41/�� ,ANG , 1az Email Address: �yu"lslims/goQc w,4va .Cvn,.
Detailed Directions To Site: k/ A'.ny 4'( f4/17 /rJ 4r e..'Aa
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Property Address:
Please Fill In The Following Information About The EXISTING Facility:
Name System Installed Under: Type Of Facility:
Date System Installed(Month/Date/Year): Number Of Bedrooms: Number Of People:
Is The Facility Currently Vacant? Yes If Yes,For How Long?
Any Known Problems? Yes e!�o If Yes,Explain:
Please Fill In The Following Information About The NEW Facility:
Type Of Facility: /4 It+4 Number Of Bedrooms: Number of People
Pool Size: Garage Other:
Requested By: Date Requested: f
(Signature)
For Environmental Health Office Use Only
Approv Disapproved `
o/'Y'
Comments: a i � e /� Cl'c F r
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Let a7z-
Environmental Health Specialist Date: '
*The signing of this form by the Environmental Health Staff is in no way intended,nor should be taken as a guarantee
(extended or limited)that the on-site wastewater system will function properly for any given period of time.
Payment: Cash - Check Money Order # Amount:$ O r- mate:
Paid By. Received By:
Account#: (l Invoice#:
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DAVIE COUNTY HEALTH DEPARTMENT
_ IMPROVEMENTS PERMIT AND .CERTIFICATE OF, COMPLETION#h,,9 0
*NOTEAssued in Compliance With Article II of G.S.Chapter 130a `
Sanitary Sewage Systems Permit Number
,Name's ''`T� rJy o, ccr o i�l Date ' _: -N26 2\9 3
Location ��"C �� cry. 1 \�\ �, CA,5 ��\��a .� _. �.
Subdivision Name Lot No. Sec. or Block No.
Lot Size 50 X House Mobile Home _— Business Speculation
No. Bedrooms No. Baths _�— No. in Family _
Garbage Disposal YES ❑ NO 0� Specifications for System:
Auto Dish Washer YES ❑ NO pr
Auto Wash Ma^hive YES p NO D/
lD �
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.
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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 � �"•–
3' b 1.
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.
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APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
•M, Davie County Health Department
• aa
Environmental Health Section l
P. O. Box 665 / v
Mockoville, NC 27028
1 . Application/Permit Requested By JEWL1
Mailing Address T ic> -�2-- NO C- L'." ^Ile
e /`t7
Home Phone 2—��1-P Business Phone 4'ti /;
2. Name on Permit if Different than Above /�
3. Property Owner if Different than Above l_'D 0- cc JW az
4. Application/Permit For: 0 General Evaluation S/Tank Installation
5. System to Serve: House Mobile Home Business
Industry Other 0 Unknown
6. If house, mobile home: Subdivision Sec. Lot#
No. of People Dwelling Dimensions
No. of Bedrooms 7 Basement/Plumbing
No. of Bathrooms Basement/No Plumbing
0 Washing Machine 0 Dishwasher 0 Garbage Disposal.
7. If business, industry, other: Specify type
No. of People Served No. of Sinks
No. of Commodes 1 No. of Urinals
No. of Lavatories No. of Water Coolers
No. of Showers
8. Type of water supply : �,V Public 0 Private 0 Community
� t
9. Property Dimensions „��(`� J D
10. Sewage Disposal Contractors
11 . Do you anticipate additions/expansions of the facility this system is
intended to serve? 0 Yes No
If yes, what type? �C
*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 f6r all
charges incurred from this applica on.
Date Signature
Directions to Property :
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DCHD (10-89)
k• DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
_ Soil/Site Evaluation
NAME \ ��� - � � DATE EVALUATED - a - 91 .
ADDRESS S A cc1 a PROPERTY SIZE I ,� o ' X 15 d
PROPOSED FACIILTY \J J s 'J Q LOCATION OF SITE Q)
Water Supply: On-Site Well Community Public
Evaluation ByZ�,_t- Auger Boring Pit Cut
FACTORS 1 2 3 4
Landscape position S S .S
Sloe Z - -Q - -° - I
HORIZON I DEPTH
Texture group "C; C Cl-
Consistence Consistence - =I
Structure Q, Z \Z
Mineralogy
HORIZON II DEPTH -S
Texture groupC L I -ScL SCI_
Consistence 'S
Structure
Mineralogy
HORIZON III DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS S-5 S'S s -519
RESTRICTIVE HORIZON —
SAPROLITE — — —
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE _ v 3 - . b 5- ,t p -,
SITE CLASSIFICATION: Q • S EVALUATED BY:
LONG-TERM ACCEPTANCE RATE: 3 a OTHER(S) PRESENT: \ � n�
REMARKS: S C.� ( _ , "
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-Sirigle grain M-Massive CR-Crumb GR-Granular ABK-Angular blocky
SBK-Subangular blocky PL-Platy PR-Prismatic
Mi neraloiry
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 watef 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(O1-901