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119 Cotton Ln 'r. u i . , >`A ..a-:."1"Z=r"`a'fi'tre ~fie` u Z. a;,'-v."'✓'S +, rr + ..o'..r`s` `f +r• • ♦o .._�., .; DAVIE COUNTY HEALTH DEPARTMENT f . IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION *NOTE:Issued in Compliance With Article II of G.S.Chapter 130a -San it ry Sewage Sewag5eu:�S�yi`st ms �i ' � / Permit Number mber /7 � Nam ` Dat N0 70 Location i Subdivision Name Lot No. Sec. or Block No. Lot Size House / Mobile Home 74,_ Business -- Speculation No. Bedrooms .No. Baths / No. in Family / _ Garbage Disposal YES ❑ NO Spe ifications for-System: Auto Dish Washer YES �NO 'p Auto Wash Ma^hine 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. Y -1^ r,t Ic% 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_ r7TT8" aus0� r 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. 2 APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PER Davie County Health Department 3 Environmental Health Section 2 P.O. Box 665 Mocksville, NC 27028 1. Application/Permit Requested BV // Mailing Address � <S V 2 r- ( U Home Phone ��- / n Business Phone 2. Name on Permit if Different than Above 3. Application/Permit for: ❑ General Evaluation eptic Tank Installation 4. System to Serve: ❑ House obile 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 ,L f7-w-ashing Machine No. of Bathrooms ❑ Dishwasher Dwelling Dimensions L ❑ 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: ❑ Public nvate ❑ Community 8. Property Dimensions Sewage Disposal Contractor 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes B-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: hamQ- (:��Y, 0kJ-A- (�- C� This is to certify that the information provided is correct to the best of my knowledge, and I unerstand I am responsible for all charges incurred from this application. 3 - 2y 3 ns DATE SIGNATURE CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY Fanddisposal ECK ONE: ❑ 1. I OWN the property. . 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 treat ent system. , 2L/ 9 �U DATE SIGNATUhE DCHD(12-90) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation NAME SOl(�i/h/ DATE EVALUATED ADDRESS PROPERTY SIZE 2�, PROPOSED FACIII,TY LOCATION OF SITE " '� 2006- Water Supply: On-Site Well Community Public Evaluation By: Auger Boring Pit Cut FACTORS I 2 3 4 Landscape position Slope % -- HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH '� r Texture group Consistence Structure 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 , 14 SITE CLASSIFICATION: 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 Mineralo¢y 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 watef 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 ■■■■■■■■/■...■■■■■■■■■■■■■■■■■■■■.■n■■.■.e■.■.■■e......�■ ■..MIEN ■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■MIEN■■■.■e■.■/...■..■..■■■..■e■■ ■.■..■.■.■MM■■■.M.....■■..Mei..■.■M■....■■■■■■.■.■■■■■■..■■....■..■ MOON ■.....■■■■.■■■..■■■...■.....■■...■■■.■.■.■■.■.■.11■..■■.■.■/....MIEN ■■■.■..........■e■■■■■■■■■■..■.. ..■■■..../■■..11.......■■■■i■■.■■ ■..■.■e■■e....■■■■■■■■■■..■.■■■■■.611111■.....■.■..IIl�ii.■■.■■■■.■■■■ ■■■■■.....■....■.....■■■..■■■■■■■■ ..■■........moi......■■■./■..■■� ■.■..■■■.■■■■■■■■■■■■■■■■■■■■■■■ ■■■.■■■.. ■/MIEN■I■■..■.■e■■..■ ■■■ ■..■.■■..■■■..■.■..■..■■M....■■......■.■./Li\��.■■�I.CM.MM■M■M.M■MM■■ ■■e■■■■■■■..MM■■■■■■■■■■■■■..■....■■I.../■■/.....I.....M■ ■.■■■■■ U■..MIEN ■..MIEN ■■.MIEN ...■.■ , L��..�I .■... ' ■.... ■.MIEN■ , ■M■M■■ ■■■■■■"eM■M■M ■■■■■■�■:N..= ■■.Ei■�iM■■N■■ ■M■MM■� ■....■■.■■■■■■...........■■■■...■■■.■■.M..■.M■■e11.■■■.MMM.■.■M■..■ ■■■■■..■.......■■.■.■■■e.....M■■..■■■eM.M ■■■e■.u.-M■■.■■■■■e.■■■■ ■.MIEN■e.......■.//=//:i:://======�w�1■...■11.. M/ . ■■ ■ on ■■■■■■ ■■■■■■■■■■■■.c■■■■�■■■�i■.■.i■■■■■Mil`■■.■■■1�.i:ini ....■..ue. .■.■ ■.■■.........■.■.uM...a.MMi■.■.MMMeaIE�■■=��=■.■M.�i� ■■■■■M..M■M1M■■■■ ■.■.■....■■■■........■■■■■e...■.■..Nae .. ..� MM ■■M■.MM MIEN.NEI ■ No■ MSM eNMMMM1MM ................................ . . MMMMMMMM .■/.■■■■■■■. ■■.■MMM.■■■■M■.■.MM..M■■■■..■...M■.IE..■.. ■ ■■.■■■■■■■■■.■■■■ ■MMMMMM .M■■MMMMMIE■ MMM■■MMM■■eM■■MMMaM■�■■ ■MMMMMM■M■IEM M■M■■ MMMMMM: ::::C:C::::::C::::=::::�'i.:'::::C::: :�:: ■■■■■...MIEN■..M.■.■■■....■■■..■■..■■./ ■MM ....M...■.■ ■■■.■.■■. ■■■....■■.■..■■■■.■■..■■■■■■■■■■ ■■■■■■■■■■■■■■.■.■■■.■■■■■■M■■■■ .................... ............................................. ...................................... ........................... .................................................................. .................................................................. NO ......■.................... ..................■■■.■■N■■■■NN■ ............■.................�■■M■.........MMMMMMMMMM■MMM■M■M■ /■■■■■ ■■■■■■■■■■■■■.■■■■■■■■■VM■M■M ■■■■■..■■■■.M■NN■M■...■■..■ a Davie County Nealilf 7ye arbnent and .lame Nealtlncy 210 HOSPITAL STREET/P.O.BOX 885 MOCKSVILLE.N.C. 27028 PHONE:(704)834.5985 Johnny Buelin Rt. 8, Box 373 . Mocksville, NC 27028 Re: Site Evaluation Jack Booe Road - 1 Acre Dear Mr. Buelin: As requested, a representative from this office visited the aforementioned site on March 30, 1993. 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, Aeo;.QA' ' Robert B: Hall,: Jr. , R.S. Environmental Health Section RH/wd _ Enclosure