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174 Edgewood Cir .• a_.-:�.. a'ivy -" . . . ..... _.... . r °ate' DAVIE COUNTY HEALTH DEPARTMENTroo.op * IMPROVEMENTS PERMIT ,AND CERTIFICATE OF COMPLETION _*NOTE:Issued in Compliance With Article 11 of G.S.Chapter 130a Sanitary Sewage Syst s Permit Number R Name o Date { / 11'1 No 7725 Location ____1��Li CN sla U W\o c- o U S - R ar. �6 O Is- FSubdivision Name 9 0Z Lot No. 410 W14 FSec. or Block No. t f Lot SizeHouse Mobile Home _ Business _— Industry No. Bedrooms .No. Baths No. in Family � — " .Public Assembly Other Garbage Disposal -x YES 'El , 'NO Specifications for System: Auto Dish Washer YES gy N0 ❑ l p vp °` ` s � _ try Auto Wash Ma^.hine YES V "NO,i❑ 1 Type Water Supply _ O v. r5"�.y 00 u �< 'This permit Void ifse 'a'g'e system described below is not installed withiri 5 years from date of issue. This permit is,subject to revocation if site plans or the intended use change. { Z o A - OID �y Improvements permit by `-` a *Contact a representative of the Davie County Health Department fo 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 mborr:.704.634-5985. Final Installation Diagram: Syst m Install d i s �M a • a •s r , Certificate of Completion Date 6 " 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. if APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT 0! o o Davie County Health Department Environmental Health Section In•.�C,,.,OV P. O. Box 665 W r j�IIED Mocksville, NC 27028 SGP Z 199 l /1 Q 1. Application/Permit Requested By ^NI '\ � -- -------- Mailing Address R !Y 2 2 Home Phone Q �'�S ✓7,.�- ,L e . �. 7d z� Business Phone 2. Name on Permit if Different than Above 3. Application for: !V General Evaluation a Septic Tank Installation Permit 4. System to Serve: House ❑ Mobile Home ❑ Place of Public Assembly q �D'11 ❑ Business ❑ Industry El Other ❑ Unknown AqJG8 " �1.1-D� 5. If house, mobile home: Subdivision E D G e ry o o Section Lot # r ❑ Basement/Plumbing No. of People ❑ Basement/No Plumbing No. of Bedrooms 3 ;W Washing Machine No. of Bathrooms el Dishwasher ! L Dwelling Dimensions ��x 3 o ;<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: X Public ❑ Private ❑ Community ! 8. Property Dimensions Z-',, X � S� f 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: W e.4se eq I L 1 Q2ee� o Q SR Aj DA Q do)C ` ,Lo T G$ T�/Qvu��/ uJ yeti r�e,e�r resT .rs '— � ReIAJd. Ague /�5 cJP wou.�� lte O `I3 00 roGewco 0 ° To �e o,J St T� . E4GewooO ee 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. 1 OWN the property. IV 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 0 T l S C Ajtl(� P P to conduct all testing procedures as necessary to determine said site's suitability for a ground absorption sewage treatment and disposal ystem. L/ DATE SIGNATURE DCHD(1/93) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation NAME �DATE EVALUATED 9 - ho 1 q CI ADDRESSJ �` M PROPERTY SIZE �` S D PROPOSED FACIILTY tic° y 340 LOCATION OF SITE Water Supply: On-Site Well Community Public_i/ Evaluation By:t:�-"1, Auger Boring ✓ Pit Cut FACTORS 1 2 Landscape position -51 s s Slope % 07- 7 ° To HORIZON I DEPTH Texture groupC V L Consistence IF -� Structure (Z C Mineralogy HORIZON II DEPTH Z. " 6 `' Z " Texture group Consistence F '"r Z Structure k- Mineralogy HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS SS SS �S S RESTRICTIVE HORIZON - -. SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATEI1 4 y SITE CLASSIFICATION: S EVALUATED BY: LONG-TERM CCEPTANCE RATE: 1A OTHER(S) PRESENT: REMARKS: 1 ' - 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 ,3C-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■■■!■■■■!■■■■■■■■■■■!■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■ ■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■u■■■MI.■EMI■■��■w.■■■■��■■■■■■■■■■_■■■■■■■■■■�1■ �iiiiii�iiiiiii�ii�■ii�iiiiii�' liiiiii�ii�iii�iiiiii■�iiiiii� ■■■■■■■■■■■■■■■■■■■■■ease=====::■::■■■�.1M�1■■r�.■t�■�►.w��M■■■ ■■■■■■■■ ■!■■■■■■■■■■■■■■■■■a■i�■■■■■■■■■■■■■■■■�■�■■■■�,c■■- M MI■■■■■■■■■M■■■ .....................�............■.... .► ■omium � ■1■IEC■■I=■■MM■■I ■■■■■■■■■■■■■■■■■■■ani>t■■■■■■■■■■�■■M■■1!■�.M■r�■� ■■■MIME ■■■■■■■■■■■■■■■■■■■■■■■■■■.■■■iw■!!A■■■■1■■■Af��■ ■■■■■■■■■■■ ■■■■ ................■.■■tl■ono■■■M■■■■■■ME■■■IIu■ ■� ■■MEM■■ o■■■M■M■ ...................■�,t■■■M■■■■■M■■■■■■■■■�1MM■M■■■ ■E■MMEMME■■MM■■■ ■■■■■■■■■e■■■■■■■■i■1/i■■■■■■■■■■iiii■■ ■� ■■■■ ■ ■ ■ii ME■■■■■■ mom....................►..............s...s..�C�.. ■�■NI■:� .. ■■o!■■■■ ■■■■■■■■■■■■■Mn■■M■■1■■■■■��•�== ��Gai'u■ M ■ ■ ■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■i:ii!■■■■■■R: ■E■■E■■MM■■ ■■■E■■■■■■EMM■■■■ MEMEMEM MOMEMMEM so No NAMEI.■■ ■If�■■■■■■■�■■■■■■■■■■■■■■■■■i� MM ■■■■■ i■MMMIMM I■■■■■■■■■M�■■ ■■■.■■■■■■■'�■■■■■■■■■■■■■MI■■■■■■■■■■u No ■■MIMI■■MI■■■■ ■■■■■ ■■ ■■■■�■■■MI■■■■MIM■■■■M■■■■■■■■■M■■■1�Monsoon_■■■■■■■monsoon ■uo■■■■■■■■ ■■■ ■■■1�■■■■■■■■M■■■■■■■■■■e■■■■MI■■N■■■■■■■■ MI■■M■u■■■■■■■■■■■■■■■MI■ ■■■IIM■■■■■o■MM■MI■M■■■■■■■■■■■■■■■■Monsoon ■■■■o■■■■■M■oM■Moo■■■■■■ ■E■TIMI■i!'�MI■■f■■■e■■■■■■■■■■■u■■■■MIs■■■■■■■ ■■■e■■■■■■■■■■■ ■■■■■■■■ ■■■11■■■ii1■■sI■■■M■M■■■M■■■■�0■■■■■■■■■■uu ■■■o■■■■■■■■■M■■�■■u■■■■ ■■■�1■■eSi■■■I■■M■M■■■■ ■■M■M■■■■■■■■■E■■■MMI■■■■■t■■■■■■M■■■■■■■■■■■■ ...11■■■■■■■I.MIM■■E■E■ ME■■■MIs■■M■ .■■■■MI■■E■■MI■e■■MI■■■■■■■MI■MI■■■■■ !!■11■i.■■■MI'!■MI■■■■■■■■■■■■■■■■■MI ■.............■■................ ■■■■i■i■�1■■■.■■■■■■■■■■■■■■■M■■■■■■■■■■■■■■■■■■■■■■■■■■■MI■■■■■■■■■■