138 Gladstone Rd (2) DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE_ OF COMPLETION
•NOTE:Issued in Compliance With Article 11 of G.S.Chapter 130a +
Sanitary Sewage Systems X37' /'r" Permit Number
Name k ate N2, f 7 7 6
`Location
Subdivision Name Lot No. Sec. or Block No.
rLot Size House Mobile Home •� Business __ Industry
No. Bedrooms _.No: Baths — Z No. in Family_Z _ Public Assembly Other
Garbage Disposal YES ❑ NO g Specifications for System:
Auto Dish Washer YES gNO E]
Auto WasK'Ma-hine YES NO Q
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.
r-
. y
t
` 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.,
�,:00-1:30 P.M.or 4:30-5:00 P.M.on day of completion.Telephone Number:704-634-5985.
T
ge&�-
Final Installation Diagram: System Installed by —
A5D
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 PER T ;a
�
Davie County Health Department NO � R /9g�
Environmental Health Section
P. O. Box 665
Mocksville, NC 27028
1. Application/Permit Requested By / r—'O(r C k 0L d =eci( 7—C) Of
Mailing Address Q r Home Phone � �f c�
Business Phone 63 q`
2. Name on Permit if Different than Above
3. Application for: ❑General Evaluation �Se . ank Installation Permit
4. System to Serve: ❑ House /i�fb- ome ❑ Place of Public Assembly
❑ Business ❑ Industry ❑ Other ❑ Unknown
5. If house, mobile home: Subdivision Section Lot #
❑ Basement/Plumbing
No. of People n ❑ Basement/No Plumbing
No. of Bedrooms 91n:/&y3 ❑ Washing Machine
No. of Bathrooms &LA ❑ Dishwasher
Dwelling Dimensions J I Llu"'9 �� ❑ 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: CT ublic ❑ Private ❑ Community
8. Property Dimensions I 0.wu— Sewage Disposal Contractor
9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes l��
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: I I` Twn
(!5"1C�k.
tv I le
J
This is to certify that the information provided is correct to the best of my knowledge, and I ynderstanp I am respo ible for all charges
incurred from thi ap licat ion. /
b o�
AT SIGNATURE
CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY
MUST CHECK ONE: ❑ 1. I OWN the property. j] 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 pers6rrauthorized by the owner:
I hereby give consent to the authorized representativ of e D vie ounty He Ith D pa ent en r upo ove described
property located in Davie County and owned by
to conduct all testing procedures as necessary to determine s id site's suit bility fo a grog d a sor on sewag reatment
and disposal system.
,(? V
ATE SIG WkrORE
DCHD'(1193)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
ti Soil/Site Evaluation
NAME �Gr �°/�� DATE EVALUATED
ADDRESS PROPERTY SIZE �AC
PROPOSED FACIILTY /�� P LOCATION OF SITE ��ilfyDsrJi'
Water Supply: On-Site Well Community Public (/
Evaluation By: Auger Boring Pit Cut
FACTORS 1 2 3 4
Landscape positionSlope % 2
HORIZON I DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH _S/1'
Texture group _
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: A9
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
SILL-Silty play 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(01-90)
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