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767 Burton Rd (2) z1-!DAVIE COUNTY HEALTH DEPARTMENT Y - IMPROVEM6NTS PERMIT AND CERTIFICATE OF COMPLETION *NOTE:Issued in Compliance With Article I I of G.S.Chapter 130a -Sanitary Sewage Systems -Permit, Number Name , .l�. rF�/ /�/.;err , .� �f�i /�lJ Date i s`./•. r Location rn�/• /�"Y . / % :�/r<< r� -' Jel 2, `, ., Subdivision Name Lot No. Sec. or Block No. Lot Size -�! ��}�- ?r''~ House Mobile Home _11� Business Speculation No. Bedrooms 1 No. Baths — — No. in Family,_ Garbage Dispos t•, YES ❑ NO p' ^� Specifications for System: Auto Dish Washer YES NO ❑ Auto Wash Machine YES NO ❑ Type Water Supply 4'l/_�'. i't *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. U 1 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 Certificate of Completion Date '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. APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT Davie County Health Department Environmental Health Section ,RECENED JUL I P. 0. Box 665 Mockoville, NC 27028 1 . Application/Permit Requested By n GhyE I T-k 1 Y1 or Mailing Address G 3 QO K yV 1 I A I/C, r%c.0 Home Phone cI I-) E' u3 1 ! Business Phone C4 M , 2. Name on Permit if Different than Above 3. Property Owner if Different than Above 4. Application/Permit For: General Evaluation Be**"/Tank Installation 5. System to Serve: House Mobile Home 0 Business I Industry u Other Unknown 6. If house, mobile home: Subdivision Sec. Lot# No. of People Dwelling Dimensions �� X No. of Bedrooms Basement/Plumbing No. of Bathrooms 1 Basement/No Plumbing No. Machine dishwasher 0 Garbage Disposal 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 ff"Private Q Community 9. Property Dimensions a'CAX. > -ele� / 10. Sewage Disposal Contractor 11'. Do you anticipate additions/expansions of the facility this system is intended to serve? 0 Yes LI;/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. 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 �- e nck ria n Rd. - a Lv f�- Directions to Property : j DCHD (10-89) 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." 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. O. Box 665, Mocksville, N.C. 27028 Davie County Health Department Environmental Health Section Site Evaluation Consent Form LOCATION OF PROPERTY: DATE RECEIVED (office use only) yes no 1. 1 am the owner of the above described property. yes no 2. 1 am not the owner of the above described property, however, I certify that I have consent from 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 propertyand 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: �CSwner only Owners designated representative _Anyone requesting results — Only those listed below DATE SIGNATURE DCHD(t t/84) DAVIE COUNTY HEALTH DEPARTMENT Environmental`Health Section Soil/Site Evaluation NAME J�;00- DATE EVALUATED ADDRESS PROPERTY SIZE PROPOSED FACIILTY LOCATION OF SITE Water Supply: On-Site Well Community Public Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3 4 Landscape position A- .4- L Z__ Sloe % HORIZON I DEPTH Texturegroups Consistence Structure Mineralogy HORIZON II DEPTH Texture groupC' Consistence r- Structure .S' .f' ,f' f;3 Mineralogy /: / A- 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• � 5 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 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 ■■■e...n////...//i.■.■...■■.■■■ ■//■■■�■�:::�...■...e.//e..■ ■■. ■.e...■■■■.■.....s■.e....■■/.iii.■.......■■...t�n■■■..e.■■■.e■■■■■ ■■■■■■.■.■■■■■■..■■.■.■■t�iiii■i■�.i._iii■■■.■■■■■.■■■■■■■■■■■■■■■■ t..■■■■....■..■.....///.r■■��i�i�ri.��■��■■.■ice/®■D...■.....■■■.■ .................................................................. .................................................................. 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