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DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTE:Issued in Compliance With Article II of G.S.Chapter 130a
' Sanitary Sewage Systems Permit Number
Name �' r.�- (� �``�! Date N_ 6890
Location
Subdivision Name Lot No. Sec. or Block No. -°
Lot Size > A SLs�� House � Mobile Home —T Business —_ Speculation
No. Bedrooms -� No. Baths No. in Family —
Garbage Disposal YES ❑ NO p°* Specifications for System:
Auto Dish Washer YES [Y NO ❑ f e7 G
Auto Wash Ma^hine YES 0' NOS -> U� 11
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.
no
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 r�-pletion. Telephone Number 704-634-5985. T
Final Installation Diagra System Installed by
V
Certificate of Completion ( � Date Isla
'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.
♦ h
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMT-�'oEta
c.� �� �
Davie County Health Department If o tG. fv'
Environmental Health Section
P. O. Box 665 -AUG
Mocksville, NC 27028
1. Application/Permit Requested By
Mailing Addres[s�' '�
Home Phone A Business Phone �S'M e-
2. Name on Permit if Different than Above
3. Application/Permit for: ❑ General Evaluation D,,!9e-ptic Tank Installation
4. System to Serve: ouse ❑ Mobile.Home ❑ Place of Public Assembly
❑ Business ❑ Industry ❑ Other ❑ Unknown
5. If house, mobile home: Subdivision Section Lot #
❑ Basement/Plumbing
No. of People �2 ❑-Casement/No Plumbing
No. of Bedrooms a? p�11/�ashing Machine
No. of Bathrooms \ Dishwasher
Dwelling Dimensions 1,` C)Q ❑ 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: P- ublic ❑ Private ❑ Community
8. Property Dimensions \ Sewage Disposal Contractor
9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes WIN0--
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:
A-C) \/'A NN\Q_ ony- 0e.
�fi
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 SIGNATUR
CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY
MUST CHECK ONE: 1�J 1. 1 OWN the property. ❑ 2. 1 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)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
NAME -.S�sv�zw C\�a�M, DATE EVALUATED
ADDRESS 5 Q �'�' PROPERTY SIZE
PROPOSED FACIILTY � � LOCATION OF SITE .,�.>+•- C >�s- ��
Water Supply: On-Site Well Community Public
Evaluation By.'Q* �- - Auger Boring Pit Cut
FACTORS 1 2 3 4
Landscape position S' J -5 S
Slope X - 6D - fe -IG $ S
HORIZON I DEPTH 1:�1'
Texture group Cl. C t.
Consistence
Structure G C K C
Mineralogy
HORIZON II DEPTH L 3 6 L 3c.
Texture group C
Consistence T_
Structure k
mz-
Mineralogy �I
HORIZON III DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS 5S Ss S'S -SIS
RESTRICTIVE HORIZON — —
SAPROLITE
CLASSIFICATION S 5 S
LONG-TERM ACCEPTANCE RATE ,
SITE CLASSIFICATION: Q •� EVALUATED BY: �
LONG-TERM ACCEPTANCE RATE: - 4 OTHER(S) PRESENT:
REMARKS: Z_n�' - �` s -
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