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181 Foster 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 Permit Number Name t; v 5 Date - 1 N� n ' 6 65 1 Location 1 _v 5� i -4, Subdivision Name Lot No. Sec or Block No, Lot Size �f�, �`�'"may Hous Mobilq Home �. Business _ Speculation No. Bedrooms =' No. Baths No. in Family Garbage Disposal YES ❑ NO p/ Specifications for System: Auto Dish Washer.' YES ❑ NO [�'' Auto Wash Ma.hine YES (g/ NO ❑ Type Water Supply *This permit Void if sewage system described below is not installed within l years from date of issue. This permit is subject to revocation if site plans or the intended use Chang . i `I i / D 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 6d;_,,22-60 I' Certificate of Completion Date / -1 'The signing of this certificate shall indicate that the system described above has been iristalled 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 FEB 3 Environmental Health Section �,�a P. O. Box 665 Mocksville, NC 27028 1. Application/Permit Requested By ``�L&V ' L • Cv,Z Mailing Address Z '0 ( 4d Home Phone__(7�,`-t 3 4 4` Business Phone 6—S-9 7 j 2. Name on Permit if Different than Above 3. Application/Permit for: ❑ General Evaluation ❑ Septic Tank Installation 4. System to Serve: QP Mobile Home ❑ Place of Public Assembly ❑ Business ❑ Industry ❑ Other ❑ Unknown 5. If house, mobile home: Subdivision Section Lot # ❑ Basement/Plumbing No. of People Z-- v ❑ Basement/No Plumbing No. of Bedrooms ? -r" 3 P-V�ashing Machine No. of Bathrooms�Z Ta ❑ Dishwasher Dwelling Dimensions l )l-7/9 ❑ 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: ❑ Public Private ❑ Community 8. Property Dimensions Z ;�<<?e-S Sewage Disposal Contractor 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ET"Yes ❑ No If yes, what type? �->��✓S� "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: Sit 2uca r,o 5-r A r�2 ar/ �'^�-'" 1 v Pi2on4 a I 2(9 wrnv./ ��✓�ti j ' �•��S r 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 H alth 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 SIGNATLYRE DCHD(12-90) DAVIE COUNTY,HTMLTH DEPARTMENT J'- Environmental` ealth Section Soil/Site,;,4v41uation NAME �� s o o -0- DATE EVALUATED 9`1 ADDRESS 5 poli\ +� PROPERTY SIZE 2 � p PROPOSED FACIILTY , ` '�^ LOCATION OF SITE I o at e�z IY� Water Supply: On-Site Well V Community Public Eval ation By: Auger Boring ✓ Pit - Cut FACTORS 1 2 3 4 Landscape position S Slope % - 1, G _S1 d -1�" V -$ a- 730 HORIIZON I DEPTH ° ' Texture group S C-1- CL S C L' S CL S CL Consistence P1 I FT F_ Structure R C. i,7- Mine'ralo I;1 1 ._"V,l k HORIZON II DEPTH 2.kLI .ZY :2 :0 :P Textiure group 'C L Consistence F T T-t -L Structure Su S S 11 r- Mine�alogy 1 HORIZON III DEPTH Texture group Consistence Structure Minetalogy HORIZON IV DEPTH Texture group Consistence Structure Minetalogy SOILIWETNESS V V S S S RESTRICTIVE HORIZON — -- SAPROLITE — — CLASSIFICATION cvS S S LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: `Q S EVALUATED BY: LONG-TERM ACCEPTANCE RATE: OTHER(S) PRESENT: N a REM RKS: 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 fine 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 Mineralo[ty 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 ■.■..■.■.■...........irk..........■rr■■.■...0■...�.■�.i.■.■.......e..■ ■■■■■■■./�1! l■■■■■r/■11.■11.■'i■■..■11■■.■■.Ii�C�ii./I■■■■■■■■■.■■■■■■■■ ■■■■■■.�i►C!�. iso..l\Ir�...d./..■...I[■.i•iiGi%..■.i•\.%.■.■■■■■..■.■■.■■■ ■■■..■.\�!%%■11..\.\`::l■%../I.�i•i•�Giai....■�I.i�%i•I✓r�Ciiii..■.....■..■■ ■..■■■..■r1■■��■■\�.Ii■.■e■If[1..../i��ii.rl■\i`�iI'/��iii.■■■...■■....■ OEM momor ■.■■■■■■.■.......rl....l■.II■■..■x......11■■....'�.■...■....■.....■.... e■.■■■ ...■.■ ■■■M.■ ■.......,!■........■■..11...►\►�!C..►`l►iCi a!r:■■11.......■.n...■......■..■ ■.....■■..■■■.■................. >"..........■.■tee..........■■ ■■.■ ■■.■...■.■!!■■■■■.....■..■■.■■..[J■■■■..■■■■.■iili�l..■..■.■■.I�■�■■.■ ■■■■■■■ ■■■ ■■■■■■■■■■■■■■.■■■■■■■■■.t.7■■■■■■■■wt■■■■■■..■■■..■■ ■■..............■....t.....■■■.■ ■a.s.[i.....■■..��.■.........■.■■■