446 Duard Reavis Rd (2) "`•�#r -�.- _ 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 Date �y �� ND 6 218
Location
Subdivision Name Lot No. Sec. or c No.
Lot Size .f>u "/ 'w0 House Mobile Home_ Business Speculation
No. Bedrooms No. Baths , No. in Family _
Garbage Disposal YES E) NO [R' S ecifications for System:
Auto Dish Washer YES ❑ NO
Auto Wash Machine YES E? 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.
1
11
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Improvements permit by ---�`°'N`
*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
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C&O �T
\ ertifi of Comp etion Date
"The signing of this certif\ a shall indicate-t a$stem described above has been installed in compliance with
the standards set forth in the pbo. -re ulation, buts all in NO way be taken as a guarantee that the system will function
satisfactorily for any given period of time.
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• APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department
c Environmental Health Section
) Db0p P. 0. Sox 665 V:CE`v53
MOckoville, NC 27028 R
1 . Application/Permit Requested By acz�G�F�/i/S 1
Mailing Address ,'ZT6 -Z ay Z Z c fr?00-/-;rSfi ,Af N(f Z 2CO e g
Home Phone 4�c1� ' 73 F� Business Phone &Scl-6 0 411
2. Name on Permit if Different than Above AM
3. Property Owner if Different than Above o u rd J� l��ca,yr f
4. Application/Permit For: C) General Evaluation g.-Z-/Tank Installation
5. System to Serve: C) House p. -Mobile Home Business
Industry u Other Unknown
6. If house, mobile home: Subdivision Sec. Lot#
No. of People Dwelling Dimensions
No. of Bedrooms Basement/Plumbing
No. of Bathrooms 7 Basement/No Plumbing
Washing Machine Cj Dishwasher 0 Garbage Disposai
7. If business, industry, 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
8. Type of water supply : C Public private a Community
9. Property .Dimensions
10. Sewage Disposal Contractor
11 . Do you anticipate additions/expansions of the facility this system is
intended to serve? o Yes 0-No
If yea, 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.
This is to certify that the information provided is correct to thE_
best of my knowledge, and I understand I am responsible f ,r all
charges incurred from this application.
,d--/g - 9 0 ZZ4=')�,'
Date Sign tura
Directions to Property :65
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ON �ttl�lLD /c �R-v�.1 R o u i
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DCHD (10-89) -
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` DAVIE COUNTY HEALTH DEPARTMENT
ENVIRONMENTAL HEALTH SECTION
SITE EVALUATION CONSENT FORM
1. Complete the form below and return to the Davie County Health Department.
2. Carefully follow the procedures as outlined in the enclosed "Information Bulletin."
1
NOTE: THE ABOVE MUST BE COMPLETED BEFORE A SANITARIAN WILL BE ABLE TO
BEGIN THE REQUESTED EVALUATION.
DETACH HERE AND RETURN TO: Davie County Health Department, Environmental
Health Section, P. 0. Box 665, Mocksville, N.C. 27028
Davie County Health Department
Environmental Health Section
Site Evaluation Consent Form
LOCATION OF PROPERTY: DATE RECEIVED
wadIl
(i��//S J�� (office use only)
yes 1. 1 am the owner of the above described property.
es , no 2. 1 am not the owner of the above described property, however,I certify that
have consent from P LA2rdU IS , owner to obtain a
owner's name
site evaluation by the Davie County Health Department for the purpose of
determining the suitability for a ground absorption sewage treatment and
disposal system.
yes no 3. 1 hereby give consent to the authorized representative of the Davie County
Health Department to enter upon the above described property and conduct all
testing procedures as necessary to determine its suitability for a ground
absorption sewage treatment and disposal system.
DATE SIGNATURE
4. 1 hereby authorize the Davie County Health Department to release site
evaluation results from the above described property to the following:
Winer only
— Owners designated representative
—Anyone requesting results
— Only those listed below
DATE SIGNATURE
DCHD 01/84)
V
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
NAME AV 1S DATE EVALUATED - - 9 D
t ►
ADDRESS PROPERTY SIZE bo �'p(�o a
PROPOSED FACIILTY \��• o�rK' LOCATION OF SITE Q h
Water Supply: On-Site Well Community Public
Evaluation By:C: l- Auger Boring lJ Pit Cut
FACTORS 1 2 3 4
Landscape position 5 5 -S
Sloe % O - O -$ C) -'Ga O 7Fo
HORIZON I DEPTH ' Le Z '' "
Texture group (� I- C
Consistence - 2 F•T
Structure A V,
Mineralogy z i ' 1
HORIZON II DEPTH LA 2` S ` jq
Texture group C
Consistence _ --C
Structure Nf,
Mineralogy 1 1 j+')
HORIZON III DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS 5 S 5 S S SS
RESTRICTIVE HORIZON
SAPROLITE - —
CLASSIFICATION S W& s I V.S.
LONG-TERM ACCEPTANCE RATE o S-L
SITE CLASSIFICATION: 'S EVALUATED BY:
LONG-TERM ACCEPTANCE RATE: yy OTHER(S) PRESENT: X. �.n
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
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