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230 Fulton Rd 4�x 7.. _.„:,;..�„-r.y.s,:.-:,d ,r.� -. ., H�er3•ws -. .... T• _ _ - DAVIE COUNTY HEALTH DEPARTMENT t `f, IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION *NOTE:Issued in Compliance With Article I I of G.S.Chapter 130a Sanitary Sewage Sewage Systems q Permit Number —1 Name h b �'�\ Date 4w 1 N2 7 5 9 „� 'C1 V�ANCo O Location _ L1 Ecar Subdivision Name Lot No. Sec. or Block No. �. Lot Size c�rs� ” ' House `' - Mobile Home Business,-- Industry No. Bedrooms L+ No.',Baths _2 No. in Family — Public Assembly Other Garbage Disposal YES ❑ NO [ ''�. ,• ;, Specifications for�System: Auto Dish Washer' YES C�3' Nd' E] /'. cz,6 Auto Wash Ma^hine YES [�' NO Q �U 0 � 3 'X ! 2i r ��� •.,�. pe Water Supply .— *This rmit Void if sewag6system described below is not installed within 5 years from date of'issue. This per t_is subject to Yevocation if site plans or the intended use change. 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., 1:00-1:30 P.M.or 4:30-5:00 P.M.on day of completion.Telephone Number:704-634-5985. Final Installation Diagram: System Installed by0� p rl tJAc��o Q Dw f„ v � i Certificate of Completion _ fan'n�:, 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 jsatisfactorily for any given period of time. ;-_ s APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT Davie County Health Department r� Environmental Health Section P. O. Box 665 u u `J Mocksville, NC 27028 ��AV 2 4 1984 1. Application/Permit Requested By jKW f Agl/�� Mailing Address hvh 2 A0Z 31 Home Phone UQ,✓Ce n/C Z?00 6 Business Phone 2. Name on Permit if Different than Above 3. Application for: ❑General Evaluation 19 Septic Tank Installation Permit 4. System to Serve: ❑ House IX Mobile Home ❑ Place of Public Assembly ❑ Business ❑ Industry ❑ Other ❑ Unknown 5. If house, mobile home: Subdivision Section Lot # ❑ Basement/Plumbing No. of People ❑ Basement/No Plumbing No. of Bedrooms Washing Machine No.of Bathrooms 2 Dishwasher Dwelling Dimensions7Z Att bk 72 4e el ❑ 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 �� ❑ Private ❑ Community 8. Property Dimensions �- �4� a'C' Sewage Disposal Contractor 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes ❑ 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� easy- ,Nard cork 7v r, L e& o /s woad ai7L for1� .� ✓ 1"1' 64 Av 1\i 411- twyo 0/40 Tu r,- �` 1/e AVAQ Q �o ,6e �lF� Jni �6�� PBf C 0� ���� 4C�/'►>�� �Sd tel{��vJ���� I�10 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 SIGNATURE CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY MUST CHECK ONE: 1. I 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(1193) i DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation / Q NAME DATE EVALUATED E7 I ADDRESS r S A tr fl PROPERTY SIZE °� ►�, PROPOSED FACIILTY D m -t1 LOCATION OF SITE Water Supply: On-Site Well _ Community Public Evaluation Byt4,,L Auger Boring Pit Cut FACTORS 1 2 3 4 Landscape position Slope % c- a cd- -a - S -77o HORIZON I DEPTH Texture group G L C t~ C 1. C L. Consistence rZ V7_ VZ Structure Y_ C. 7 G Mineralogy HORIZON II DEPTH VA) `' Ll2" 42." Texture group 01 C C Consistence ` r� Structure c7- Mineralogy 7-Mineralo HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS f 53 S SS RESTRICTIVE HORIZON - — SAPROLITE CLASSIFICATION �l? LONG-TERM ACCEPTANCE RATE \ ,� Q ` SITE CLASSIFICATION: — EVALUATED BY: - LONG-TERM ACCEPTANCE RATE: �� OTHER(S) PRESENT: REMARKS: -C_C*w ` S-a� �r �n a�..- �� w-A 2 �oC .t- 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 :lay 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 MEMO■■■■■■■■.■■.■ee■e■..■■■■■■■■■■■.■■■....■■■.■■..■...■.■ ■..■■■ ■■.■■....■■...■■■■■■■■■■■■e/■■ecce■.■■■..■...■.■....■■■.......■■.■ ■■■■■■■■■■■■■■eee■■■■■■■■■■e■/■■■■■eee■■■.■.■..■...■.■....■.■...■■ ■■■e■■■..■.■..■■.■■■■.eee.■■■e■■M■■■.■e■M■■■■..■■.■....■■.■■.■■■■■ ■■■Mee.■■■.■/■■■ee■■■■■■■■■■■ee■ ■■■■■ee■.e■■e/■.■.e...a■■..ee■■■ ■..■.■...■.■....■■■.■■■■■■..■■■■■■■■....■■..■.......■■■■..■....■■■ ■■.■■e■.■■■■.eee■■■■■■■■■■■■■■■ ■ee■■■■.■.■■■■...e■■■■/e/■■■■.■■ ■■.■/.....■■..■■■■■■..■■.■■.■.e.■...■■....■..■■■.■ ■■.■■■■■■.■... 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