222 Cedar Creek Rd -. - '}.. � � � T��i J r «�'.i:.r•. ): • . i'"a(.°� sA .Y.', 1•. 3-. .:.1'.i)i t _ •�\.�7 `^)-. ..-. r...t''�.s e 3
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DAVIE COUNTY HEALTH DEPARTMENT _rl
IMPROVEMENTS PERMIT AND .CERTIFICATE OF COMPLETION'
*NOTE:Issued in Compliance With Article 11 of G.S.Chapter 130a .
Sanitary Sewage Systems t� Permit Number
Name A v) `. Date 0
N'
642 1
Location �" �� �`� r��! -t- 1 r� S \ c� N - F� �c�. �'i 1 cls
V. 'nth
VA
Subdivision Name Lot No. Sec. or Block No.
Lot Size 's House Mobile Home _T Business Speculation
No. Bedrooms 3 No. Baths No. in Family �^
Garbage Disposal YES p NO M"' Specifications for System:
Auto Dish Washer. YES p" NO [I �Q,.. -V •.- 13 s
Auto Wash Ma,.hine YES W-NO E] 1 —
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.
j,
use►
C
Improvements permit by
*Contact a representative of the Davie County Health Department fo final i pection this system between 8:30-
9:30 A.M. or 1:00-1:30 P.M. on day of completion. Telephone Num r 704' 34-598 .
Final Insta at Diagram:II ion Dia System Install d by
y
3-3&
Certificate of Completion Datesa
;
*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
r Environmental Health Section
P. 0. Box 66S —RUE.M NAYi
Mockoville, NC 27028
1 . Application/Permit Requested By Vzlrry 404ndaee: A/. k
Mailing Address iO4" Ito�;BOX 4lg; (tel! 1 LAS-6Y?-6X/f21 - hfil,42716 7
Home Phone 914-1624,905 Business Phone 19I -7:96 L?IAJ0
2. Name on Permit if Different than Above nn
3. Property Owner if Different than Above
4. Application/Permit For: A General Evaluation 0 S/Tank Installation
S. System to Serve: ( House n Mobile Home 0 Business
LL Industry u Other 0 Unknown
6. If house, mobile home: Subdivision /VIR Sec. Lot#
No. of People Dwelling Dimensions
No. of Bedrooms Basement/Plumbing
No. of Bathrooms Basement/No Plumbing
g_ Washing 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 Private 0 Community
9. Property Dimensions /7 ! «1 AC
10. Sewage Disposal Contractor-
11 . Do you anticipate additions/expansions of the facility this system is
intended to serve? 0 Yes No
If yes, what type?
*NOTE: Improvements Permits shall be valid for a period of S
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.
Llzn,e Y��
Date Signature
Directions to Property : // ki
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DCHD (10-89) C40 ait
Oro,
DAVIE COUNTY HEALTH DEPARTMENT
ENVIRONMENTAL HEALTH SECTION
V 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
have consent from )od Q- 4j4&LAj6A 2 , owner to obtain a
o per'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 conductall
testing procedures as necessary to determine its suitability for a ground
absorption sewage treatment and disposal system.
DATt SIGNATURE
4. 1 hereby authorize the Davie County Health Department to release site
evaluation results from the above described property to the following:
— Owner only
— Owners designated representative
Anyone requesting results
Only those listed below
.4-
0 Llj
Y)-
DAT SIGNATURE
DCHD(11/84)
' DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
NAME _ �\s �? DATE EVALUATED
ADDRESS S PROPERTY SIZE I 1 ( I C5 2
PROPOSED FACIILTY - LOCATION OF SITE
Water Supply: On-Site Well Community Public
Evaluation ByC_cl� Auger Boring ✓ Pit Cut
FACTORS 1 2 3 4
Landscape position
Slope % -f ° S- 19-
HORIZON IDEPTH 6" (0 '
Texture groupC L L L
Consistence - 1,
Structure tZ Q_KC
Mineralogy ,
HORIZON II DEPTH
Texture group
Consistence 'Z
Structure e, �11
Mineralogy
HORIZON III DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS S S S S
RESTRICTIVE HORIZON
SAPROLITE -- —
CLASSIFICATION Zz S
LONG-TERM ACCEPTANCE RATE S>-
% , .
SITE CLASSIFICATION: QR_ .�- EVALUATED BY:
LONG-TERM ACCEPTANCE RATE: •�) OTHER(S) PRESENT:. O tsz,sU-
REMARKS: cr.,
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