1705 Cana Rd 7 '1.., =; ' r DAVIE COUNTY HEALTH DEPARTMENT
4 IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*-NOTE:Issued in Compliance With Article 11 of G.S.Chapter 130a ,
:.Sanitary Sewage Systems 1 sI �`* Permit Number
Name . �- Date No 6100
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Location
i
Subdivision Name Lot No. Sec. or Block No.
Lot Size House Mobile Home Business Speculation
No. Bedrooms -IF _ No. Baths — 12— No. in Family
Garbage Disposal YES NO ❑ Specifications for Syste ,Q U
Auto Dish Washer YES NO ❑ /
Auto Wash Machine YES NO ❑ n
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.
i
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:,,d// -Sys em Installed by
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Certificate
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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
P. 0. Sox 665
Mockoville, NC 27028
1 . Application/Permit Requested By W4LI E- 0), IY1ASOtJ
Mailing Address 1,59S fl4uSE-) RQ Lzw',j$y1LLE Ny 8/702,:�,
Home Phone (q, 1=qhs -Z/ Business Phone
2. Name on Permit if Different than Above
3. Property Owner if Different than Above
4. Application/Permit For: lC) General Evaluation an Installation
5. System to Serve: VHouse u Mobile Home 0 Business
0 Industryu Other 0 Unknown
6. If house, mobile home: Subdivision Sec. Lot#
No. of People n Dwelling Dimensions 5-6- /X 3 o `
No. of Bedrooms 3- 7 Basement/Plumbing
No of Bathrooms Z Basement/No Plumbing
67washing Machine Vishwasher p;"Grbage 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 (Private Q Community
9. Property Dimensions t ob/ X I too0 /
10. Sewage Disposal Contractor
11 . Do you anticipate additions/;>No
ansions of the facility this system is
intended to serve? 0 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.
This is to certify that the information provided is correct to trie
best of my knowledge, and I understand I am responsible for all
charges incurred from this application.
7�/ho 1V M. //l
Date V Signature
l (a0 ! -Kb2 4 1c) &AIQ IQD — A26&Y aA(4rFT- AMYSS
Directions to Property :
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FRvitil� eENTE2,,
-EASE CALF. U.S -7-6 MEET— (AU-/ SITE-,
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DCHD (10-89)
DA
VIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
M Soil/Site Evaluation
NAME N 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
Sloe %
HORIZON I DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH
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
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
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
DAVIE COUNTY.HEALTH DEPARTMENT
Environmental Health Section.
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION �Q
Name Date
Address Lot Size
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position S S
PS PS P,
U U l'1
2) Soil Texture (12-36 in.) Sandy, S S
Loamy, Clayey, (note 2:1 Clay) PS, S S
U tu
3) Soil Structure (12-36 in.) S S S
Clayey Soils PS S
(� U
4) Soil Depth (inches) S S
(� (qS) PS S
a" `((�� U
5) Soil Drainage: Internal , 01,5 S
Op ) S P
3 � u
External SS
S S P
U U
6) Restrictive Horizons
7) Available Space S
PS S PS S
U U U
8) Other (Specify) S S S
PS PS PS F S
U U U
9) Site Classification -(
U—UNSUITABLE //S—SUITABLE Provisionally Suitable
Recommendations/Comments: orw 4V
��e�/ `err
Described by �,�! Title �1, ?!1 Date
SITE DIAGRAM
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S
UCHD(6-82)