P6467 Country Ln .Lo
DAVIE_COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND .CERTIFICATE OF COMPLETION
*NOTE;Issued'in Compliance With Article I I of G.S.Chapter 130a l:
Sanitary Sewage Systems Permit-Number
Name- 2 A r, Date Alm— N2
Location / 64'6 7
Subdivision Name Lot No. Sec. or Block No.
Lot Size House _ :� Mobile.Home Business Speculation
Nod Bedrooms No. Baths— _ No. in Family —
Garbage Disposal YES. ❑ NO [ Specifications for System:
Auto Dish Washer YES NO ❑ /.�,, ,�
Auto Wash Ma shine 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.
Improvements permit b -- /
*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
m
o "
0
Certificate of Completion � �� Date
"The signing of this certifi ate sha I 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.
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
NAME ���//�9� DATE EVALUATED
ADDRESS PROPERTY SIZEf/�'
PROPOSED FACIILTY /44LOCATION OF SITE
Water Supply: On-Site Well Community Public
Evaluation By: Auger Boring Pit Cut
FACTORS 1 2 3 4
Landscape position L 1'-- L
Slope % -'- `-
HORIZON I DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH
Texture group e- _4C
Consistence Ci
Structure S Sb _5 /e
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: f/
LONG-TERM ACCEPTANCE RATE: Y 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
Mineralosty
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
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section 3�
P. 0. Box 665
Mockaville, NC 27028
1 . Application/Permit Requested By
i
Mailing Address /l
Home Phone �4 ����� Business Phone
2. Name on Permit if Different than Above
3. Property Owner if Different than Above
4. Application/Permit For: 0 General Evaluation S/Tank Installation
5. System to Serve: [House u Mobile Home 0 Business
L Industry u Other 0 Unknown
6. If house, mobile home: Subdivision Sea. Lot#
No. of People Dwelling Dimensions go
No. of Bedrooms 0 Basement/Plumbing
No. of Bathrooms Basement/No Plumbing
Washing Machine 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 Watpr Coolers
No. of Showers
8. Type of water supply : Public 0 Private 0 Community
9. Property Dimensions )U 0
10. Sewage Disposal Contractor —9-m-' � -
11 . Do you anticipate additions/expansions of the facility this system is
intended to serve? 0 Yes ;J�-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 trice
best of my knowledge, and I understand I am res onsible for all
charge incurred from this appl cation.
Ua a S ' gnature
Directions to Property :
a
DCHD (10-89)