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P6672 Gladstone Rd - - -+-« �. 'r ., }z<, �(^- r+ :♦ �- ,,,,,.}- .Sn-cam e�: v �� .S- ��,� DAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENTS PERMIT AND .CERTIFICATE OF COMPLETION *NOTEAssued in Compliance With Article 11 of G.S.Chapter 130a Sanitary Sewage Systems / Permit67­2' N+umrber /--! Name ,F� �`,�� Ai !� '1��<cc�'r�' Date z„��i 1 Ne s+V€J 7 G Locationf�i 5�=' �1��Ai/ JG,�Jr �.✓ .� f Subdivision Name Lot No. Sec. or Block No. Lot Size A House —Mobile Home _� Business Speculation No. Bedrooms s No. Baths* No. in Family Garbage Disposal YES p NO p� Specifications for System: 'Auto Dish Washer YES p NO 0- Auto Wash Ma shine YES 2-"NO p t(' 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 b *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: Sy tem Installed by r 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 Davie County Health Department Environmental Health Section P. O. Box 665 Mocksville, NC 27028 1. Application/Permit Requested By 12 U 4-1 S Mailing Address Z�o Z 0Z Home Phone 9�� ,S 5 Sr /P 5�'f Business Phone 7y 2�' 4�0 89 2. Name on Permit if Different than Above /7 60n 1541 3. Application/Permit for: ❑ General Evaluation [Septic Tank Installation 4. System to Serve: Nr House ❑ Mobile Home ❑ Place of Public Assembly ❑ Business ❑ Industry ❑ Other ❑ Unknown 5. If house, mobile home: Subdivision Section Lot # ❑ Basement/Plumbing No.of People I ❑❑ Basement/No Plumbing No. of Bedrooms ER/Washing Machine No. of Bathrooms ❑ Dishwasher Dwelling Dimensions f &1sQ/'t �Xyg ❑ 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: ZPublic ❑ Private ❑ Community 8. Property Dimensions Sewage Disposal Contractor 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes CYNo 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: n To ��ad�S�n ,dr wl 1 ort 2 MY. F r cf� /,�twe� d wLo/�r12 Ll[9r+I es ^W 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. D/A DATE SIGNATURE CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROP7hene MUST CHECK ONE: 6d'1. I OWN the property. ❑ 2. I DO N If you checked Box #2, the rest of this form MUST be completed by the owner or a person authorized I hereby give consent to the authorized representative of the Davie County Health Department to enterproperty located in Davie Countyand owned by to conduct all testing procedures as necessary to determine said site's suitability for a ground absorp and disposal system. DATE SIGNATURE DCHD(12-90) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation NAME (�' J S DATE EVALUATED Z t__ ADDRESS PROPERTY SIZE PROPOSED FACIILTY �. //` 1-4 C LOCATION OF SITE Water Supply: On-Site Well Community Public_,_ — Evaluation By: Auger Boring t l^ Pit Cut FACTORS 1 2 3 4 Landscape position L_ L Sloe % HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH Texture groupL' Consistence Structure .� Mineralogy 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 SITE CLASSIFICATION: 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 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 Mineraloity 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 ■■■■■■..■..■■■■■■■■■..■■■■■■■■■■■■■H■NO■■■.■■■■■■.■■t■■■ ■NOON ■ ■■■■■■■.■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■.■■.■■■■.■■t.E■■■■..■■■ NOON ■■■■.■■.■.■■.■...■.■■■■■■■■■.■.■■..■tEEE■■EEE■■■EOE■■■■.■■■■.■■■.■ ■■.■..■■..■■.......■.■■.■■...■.■■.■.....■■■.EEE■■.■■■■.■■.■.■■..■ ■.■.■■.■.■■■EEE■■EE.EEE.NE.NEE.■■E■■■E.■EE■EE■EE■■■■.■..■..■■■..■■ ■■..■■■.■.■.■■t■.EEE■■■■■■.■■EE■�■■■..■■■■■..■.■■■.■■■....■i■■■.■ ■■■.■■..■■■t■ON■■■EN■E■NN.N■E■■■■■■■■■.■■ENN.EE■■■ENE■■.■■.■■■■■■■ ■■..■■.....■..■.■.■.....■■■■.■■■IEEE■■EE■EEEEEEE■E.■....■■.■.. ■■■ ■ONN■EEH.EE.NtEE■EN■■■.■OE.EtNE ■■ENOt.■EEEEEE■EEEEEEEEE.■EEC■■■ ■■.■■.■■EEE■.■■EEE.N■■■■■EEEN.N■■.■u■NE■..tEEEUEEE■EE■EEEE/■tEE■ ■■.■■■...■■■.■EEE.■E■EE.EEEEE.EE■■EE.■■EE■EEEEE■■EE.■EEEEEEEE.■■ ■ ■...■EEE■.E■.EEE■■■..EE■E■E■..NEN■■....■■■■.■....■■■.■..■■..■■..�. ■■.■EEEEE■E■■aE■■E■.N■■EE■■■■N.ENN■■t■t■■.EE..tttEEEEE■E■.N■Ott■.■ ■■.■.■.....■..■■■■.Ei'L1EE■...■.■. ■■EEE■.■.■■..■....■■.■■■■■.....■ f■■■E......■..■E■t...■■■■■■EEE■.E.........■■■...■...........EEE..■ ■■.■EEE■EE■.■■E■■,�......■■.■■EE■■..■.■..■■..■■.Eo.ri..■■.■ ■...■■■■ CCCCCC�CCCC�Y�CCC%����� CCC MENNEN EMEMEN M EEMEEMEMON ■■■■■...■......■..■�■......►.%■■■■t■■.ecce■■.e.■%■.I■■.■.■......■e■ CCCCCCCCCCCCCCCC::CC:::.:CCCCCCCCCCCCCCCCC.CC:.....�.0.............. ■..■.■EEEEEEEOE.■■EEEE EEEEE■EE■ ./�� EEEEE■.... ..`��/� NOON■.■ ■■■■■..■..t....■■■■■.■...■.■..•/..■■■.■..■■■■■■..■■.■.■■.....�NUNN ■■■■■.■.■■■.■■E...E■...E■■.Nee.■■...■......��.�...■.Eua. ■■...■�■ CCCCCCCCCCCCCCCCCCCCCCC�iiiiiiiii�.CCCCCCCCCCCC=CCCCCCCCCCCCCCCCC ■....t■.■■■■■..■■■■■■■.■.EEE.E■■�....................■.e.■eE.■..■ iiiiiiii■iii..iiiiiC��CCCCC�iiiiiiiiCCOMEN MENEM MEMEMEMEMMEN MENEM CCCCCCC�CCCCCCCCCCCCCC�iiiiiiiiiiiiiiiiiiiC■iiiiiiiiiiiiiCCCCCCC .................►/............... ........................... 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Number of bedrooms proposed Approximate area of lot `� square feet. House is to be set back ,., • feet from the boundary. I propop s�onstruct on the above-captioned property an individual type sewage-disposal system ' -g , well (Vo .This installation will be constructed so as to meet all t""e''''re�r;% menta of the local Health Department and the State .Board of Health. WELL: Site location approved by Health Department ( ) yea ( ) no. Type . Size of storage tank (Drilled,, Driven, Bored, Dug) ?flake: Type and capacity pump: Septic system to be installed to accommodate: Garbage Grinder ( ) yea ('7 no Washing Machine yea ( ) no Date: (Signature of Property er SEPTIC TANK: Working capacity ac7 o gallons NOTE: If tank has not been specifically approved by the State Board of Health, submit plans and specifications. PERCOLATION TEST RESULTS (If considered necessary by local Health Department) Hole No. 1-2-3---4—(Ki utes per inch of fall) SUBSURFACE ABSORPTION FIELD No. of nitrification lines; total lengthh22(9() feet; width inchea; total nitrification lines bottom area_. square feet. A representative of the A4,//p ti �– Health Depakment has inspected this site and finds it suits a unsuitable for the proposed installation. Well Site Location Approved by Health Department ( ) yes ( ) no. Date: ��Q _ (Signature) (Title) If there i:, any pertinent information which the Health Department deaires to convey to the reviewing officials, which is not covered above, use the back of this application. Return ori.'A nal and one copy to Farmers Home Administration County Office.