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156-172 Fairfield Rd ` DAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION *NOTE:Issued in Compliance With Article II of G.S.Chapter 130a Sanitary Sewage Syste(�s ` 1 Permit Number NO 8032Name. v. Date Location y Subdivision Name Lot No. Sec. or Block No. Lot Size j L� , , v'i Houser Mobile Home —l'1— Business -- Industry No. Bedrooms No. Baths — -- No. in Family -> — Public Assembly Other Garbage Disposal YES ❑ NO 2/ Specifications for System: Auto Dish Washer YES [2/ NO ❑ Auto Wash Ma^hine YES.Eai NO ❑ Type Water Supply--- <<. U 1 1 _, '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 ATTENTION: YOUR SEPTIC SYSTEM CONTRACTOR MUST SEE THIS PERMIT/LAYOUT BEFORE INSTALLING THIS SYSTEM. ... � .� I I r i 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 by —� V) F G � 1� S Z: s, G 'Q Certificat of Co 11 tion `— _ Date _ 'The signing of this certificate shall indicate th the stem'described above has been installed in compliance with the standards set forth in the above regulation, ut 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 PE Davie County Health Department 0 Q Environmental Health Section P. O. Box 665 5 Mocksville, NC 27028 1. Application/Permit Requested By Mailing Address b, Uy //�7. /�/ Home Phone LD k-yU !le ! C• d• a`70 Business Phone 2. Name on Permit if Different than Above 3. Application for: Q-1 eneral Evaluation Weptic Tank Installation Permit 4. System to Serve: ❑ House ❑ 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 gr ashing Machine No. of Bathrooms ❑,eishwasher Dwelling Dimensions ❑ 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: 42 `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 —4�0 If yes,what type? i '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: y 600 This is to certify that the information provided is correct to the best my knowledge, and I understand I am esponsible for all charges incurred from this applic tion. s�l� DATE S GNATURE CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY Fandd ECK ONE: [1-1<1 OWN the property. ❑ 2. I DO NOT OWN the property. ked Box#2, the rest of this form MU T be completed by the owner or a person authorized by the owner: ve consent to the authorized representative of the Davie County Health Department to enter upon above described cated in Davie County and owned by all testing proc dures as necessary to determi said site's suitability for a ground absor ion sewage treatment al system. DATE SIGNATURE DCHD(1193) Y' DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation NAME DATE EVALUATED F ADDRESS 5 P Q PROPERTY SIZE 3 t b 00 lb PROPOSED FACIILTY \K\' �� LOCATION OF SITE Water Supply: On-Site Well•-� Community Public Evaluation By:eO-�ugerBoringy Pit Cut FACTORS 1 1 2 3 4 Landscape position Sloe % b HORIZON I DEPTH Texture group cc—,A, C L Consistence Structure Mineralogyi HORIZON II DEPTH Texture groupC C Consistence Structure K 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: OT—HERS) PRESENT: N ° N3q__ REMARKS: LE END 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-Vl::-y 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 .3C--Single grain M-Massive CR-Crumb. 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