790 Fork Bixby Rd C `^ A !/
r= DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND .CERTIFICATE. OF COMPLETION .
*NOTEAssued in Compliance With Article I I of G.S.Chapter 130a
Sanitary Sewage Systems Permit Number
Name Date — rf NO '
0 L11
Location
Subdivision Name Lot No. Sec. or Block No.
Lot Size li' House Mobile Home �_- T Business Speculation
No. Bedrooms No. Baths .,tNo. in Family _
Garbage Disposal YES ❑ NO [3--- Specifications for System:
Auto Dish Washer YES ❑ NO ❑
Auto Wash Ma shine YES [j NO ❑ %` r� ..�,
Type Water Supply _
*This permit Void if sewage system described below is not installed ithin 5 years from date of issue.
This'permit is subject to revocation if site plans or he-tn�sd.usa a4ange.
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f Improvements permit by
*Contact,a representativeof 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. `
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Final Installation Diagram: 'N' System Installed by
Certificate of Completion /f=�LIZ Date L QZ
*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. '
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f U APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT AI-� f3oX,oZ'&l
Davie CountyHealth Department
t , Environmental Health Section /�C� � z
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P. 0. Box 665 �7d✓ ✓�E'• 0�,
.�, � Mocksville, N.C.27028 � 7D��
NSTRUCTION SHALL N T BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone •� 3� 3
1. Permit Req ted �. Business Phone
2. AddressEw
3. Property Owner if qmlrent than Above a 0,, Ca- -
ddress
P mit To: a) Install Alter Repair
b) Privy Conventional ZOther Type
Ground Absorption
c) Sub-Division Sec. Lot No.
System used to serve what type facility: House Mobile Home Business
IndustryOther
b) Number of people
6. ay If house or mobile home, statersize of hone and number of rooms.
House Dimensions
Bed Rooms Bath Rooms 21 Den w/Closet
b) If Business, Industry or Other, State: Number of persons served
What type business, etc.
Estimate amount of waste daily (24 hours)
7. Number and type of water-using fixtures:
commodes .9= urinals garbage disposal
lavatory a showers washing machine
dishwasher l sinks
8. a) Type water supply: Public Private Community
b) Has the water supply system been approved? Yeses/No
9. a) Property Dimensions ) "7, 03 �
b) Land area designated to building site
c) Sewage Disposal Contractor
10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve? ILO
What type?
This is to certify that the information is correct to the best of my knowledge.
Date Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
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DCHD(6a.0
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DAVIE COUNTY HEALTH DEPARTMENT
` Environmental Health Section
'w y.
Soil/Site Evaluation
NAME !/r11eJ DATE EVALUATED r
ADDRESSPROPERTY SIZE
PROPOSED FACIILTY ( LOCATION OF SITE
Water Supply: On-Site Well / Community Public
Evaluation By: Auger Boringy Pit Cut
FACTORS 1 2 3 4
Landscape position P.
Slope Z G'
HORIZON I DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH
Texture group
Consistence
Structure S'6/
111
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 1 z
SITE CLASSIFICATION: 2F � EVALUATED BY:
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
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
Mineraloity
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
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Davie County XeaN De artmerrt
and .Marne Nealtl yeney
210 HOSPITAL STREET I P.O.BOX 665
MOCKSVILLE.N.C. 27028
PHONE:(704)634-5985
September 6, 1990
Cindy S. Dunn '
P. 0. Box 2056
Advance, NC 27006
Re: Site Evaluation
17.03 Acre Tract
Fork—Bixby Road
Dear Ms. Dunn:
As requested, a representative from this office visited the aforementioned
site on September 6, 1990. The site was found provisionally suitable for 'the
installation of a ground absorption sewage system.
If you have any questions, please feel free to contact this office.
Sincerely,
Robert 8. Hall, Jr. , R.S.
Environmental Health..Section
RH/wd
Enclosure
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