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120 Livengood Rd DAVIE COUNTY HEALTH DEPARTMENT -IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION *NOTE:Issued in Compliance With Article I I of G.S.Chapter 130a `Sanitary Sewage Systelrts ��/f Permit Number Name d �-: kf , (// x/J'.� N/O` 6858 Location G •c' f1,�' yii �,° !�-i✓ ,lii"Ici f Subdivision Name Lot No. Sec. or Block No. Lot Size f�� House Mobile Home _ Business __ Speculation No. Bedrooms .No. Baths — No. in Family c;2 Garbage Disposal YES ❑ NO ❑ Specifications for System: n Q Auto Dish Washer YES ❑ NO ❑ Auto Wash Ma.hive YES ❑ NO ❑ 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. Ila 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 g - " � v f i L 1, P V;C t Certificate of Completion Date ,4� �1> - *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. r APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMI �� Davie County Health Department Environmental Health Section JUL 2 � 5992 P. O. Box 665 --------------- Mocksville, NC 27028 1. Application/Permit egu sted By tleea,�,","^A,-&� Mailing Address r 161 Home Phone ` d —J i�Jd Business Phone 2. Name on Permit if Different than Above 3. Application/Permit for: ❑ General Evaluation eptic Tank Installation 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 ❑ Washing Machine No. of Bathrooms 02,, v ❑ Dishwasher Dwelling Dimensions �^ d ❑ 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: ublic ❑ Private ❑ Community 8. Property Dimensions Cx'c Sewage Disposal Contractor 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes 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: 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 §1617XTUBE CONSENT FOR SITE EVALUATION TO BE DONE-QN ABOVE DESCRIBED PROPERTY Ftaondodisposal ECK ONE: 1. I OWN the property. ❑ 2. 1 DO NOT OWN the property. ked Box#2,the rest of this form MUST 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 procedures as necessary to determine said site's suitability for a ground absorption sewage treatment system. DATE SIGNATURE DCHD(12.90) *iJ DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation NAME 14eV DATE EVALUATED ��9 ADDRESS PROPERTY SIZE' . PROPOSED FACIILTY � ��J LOCATION OF SITE �d�'�1 ,� iY� , / ✓ Water Supply: On-Site Well Community Public_ Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3 4 Landscape position C_ Slope % --- HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH Texture group ( L Consistence ,- F r Structure s;� 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: L� 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-Film 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 ■.■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■.■■■■■■■ ■■■ri■ ■■■■■■■n.■■...■■■■■■■.■■■■■■■■.�.■■■■■■■■■■■■■■■■■■t■■■■■■tt ■■■ ■■ssttttteosttttttt■■■■■■■■■■■r�u►�t�ei�e■■ett■■■■■■■■■s■■t■tt■■.■t■■■ ...........................................■■............ ■c.■■■■■ 1MEMNON3:::::: =_=_:m:: ::::::�lMEMNON 3:::::: l::::::i� ■■■■■t■■■■■■■■■■.■■■■■■■■■■■■■■■■■.�■.:■�:C:S.■■■■■■■■■■■111■■■■■■■■ ■■■■■■■■■■■■■...■.■■■■.■■■■■■■■■ ONE ■■■fl■..■ttt.■.t■■t■.t■ ■■■■ ■..■■■■■■■■■■■■■■■■■■■■■■.■...■■■■■■.■.■.■r/■■■■■■.■■■■t■■■..■�■■■■ ■■■■■■■■■t■■..■■■■t■■■■■■e..=========.tttti�■t■ tttt■■na■ ■■t■t■■■ ■■■■■■■■■■■■■■■■.■■■■■.■.■■■■■■■■t■■t■■■■ti■■■ ■■ ■■■t■■■ ■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■..■■■■■■ttttttt■■■■ttt■■tttttttttt t■■■■■■■ ■■■■■■■■t■■■■.■tttttttt.■■.■■■tt■■■.■t■■■t.■■■■■_■■■■■■■ ■■■■■■■■ EMMEMME ON� �� :MUMME ........................................... ................. ... ................................ ................................ .................................................................. ■e■ecce■■■■c■ecce■■ee■■c■■eee■exec■■e■c■■■cccccc■■c■ccccecccccccc■