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337 County Line Rd g:. ,Vj : . >_ 011 DAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION *NOTE:Issued in Compliance With Article II of G.S.Chapter 130aoC'f�r Sanitary Sewage Systems Date q Permit Number qX Name ` NO 7 3 3 O/,,O Location \ _ Subdivision Name Lot No,/ Sec. or Block No. Lot Siz\ a C' '�' House Mobile Home Business Speculation No. Bedrp�oms No. Baths J No. in Family Garbage Disposal YES p NO Sp '�k a ectionss- or S}�stem�` Auto Dish Washer YES Q NO _ Auto Wash Ma shine YES„ ] NOS] �..,~<,C U' 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. z-.1., r cm o 1 ��• S�i C" by /��•�• 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:, )v System Installed by .y ``or c.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. A APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT ` a Davie County Health Department RECIE ED Environmental Health Section P. O. Box 665 orT 18 19" Mocksville, NC 27028 1. Application/Permit Reauested By �e:> On u.. + C2Q / 0� � Home Phone Mailing Address * a-A$ Business Phone_41-92- SJ 2. Name on Permit if Different than Above 3. Application for: a General Evaluation d Septic Tank Installation Permit 4. System to Serve: ❑ House Mobile Home ❑ Place of Public Assembly ❑ Business ❑ Industry ❑ Other ❑ Unknown 5. If house, mobile home:Subdivision Section Lot # ❑ Basement/Plumbing No.of People ❑0� Basement/No Plumbing No. of Bedrooms (ZrWashing Machine No. of Bathrooms ❑ Dishwasher Dwelling Dimensions ❑ 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 ❑ Private ❑ Community 8. Property Dimensions � a- +� C? Sewage Disposal Contractor 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes 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: ~� _ I�4A 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. n DATE SIGNATURE CONSENT FOR 5LTE EVALUATION TO BE DONE QN ABOVE DESCRIBED PROPERTY Fandd ECK ONE: X 1. 1 OWN the property. ❑ 2. 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 treatment al system. DATE SIGNATURE OCHfl'pl� A • j DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation NAME . DATE EVALUATED ADDRESS S Q`\�C PROPERTY SIZE Gs \ PROPOSED FACIILTY LOCATION OF SITE � � R Water Supply: On-Site Well Community Public V Evaluation By:.Q� Auger Boring LZ Pit Cut FACTORS 1 2 3 4 Landscape position C Sloe HORIZON I DEPTH ,L?" Iz'o� Texture group C�- Consistence Structure Q Mineralogy ;► 1 t ' HORIZON II DEPTH r �' `` Texture group Consistence Structure k, V, Mineralogy HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON -7 SAPROLITE —* --- — -- -� CLASSIFICATION LONG-TERM ACCEPTANCE RATE '-1 LP SITE CLASSIFICATION: EVALUATED BY: LONG-TERM ACCEPTANCE RATE: - 14 OTHER(S) PRESENT: N� REMARKS: sz� A J . 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 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 CCCCCCCCCCCCCCCCsiiiiiiiiiiCCCCCCCCCCCCCC'C■'iCCCCCC'iiiCCCCCCCC■'�'�CC CCCCCCC■■iiiiiiiiiiii■CiiiiiiiiiC'�siiiiiiiCCCCCe■iiiiii.CCCCC'i■CCC ■■■■■■■■■■.■■■■■■■■■■■■■.■■■■■.■■■■■.■.■■■■■■■.■■.■■■t■.■. ■■■■■■■ CCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCriCCCCCCCCCCCCCCCCC MEMEME■■■■■■.■t■■■ttt■■■e■■.tat■■■tt.■■■■■■■■■■■■■■■■■■■■■■i■■MOMME■■■■■■■■■■■ ■==iiii.CCI■�iEMEMEN iiiiiC■�3iiiiiiC■CIiC�eeCC.�■ �CCCCSCEEMEME�CCCCCCiiiiiiiit�i ■■■■■■■■■■..■■■.■■■■■.■■■■■..1'iii.■Leri+;/■.■►\■i■■■mom■■■■■■■■.■e■■■■■■ ■■■■■■■■■■.■.■■■■■■■■■■■!a■■■■■■■■■■t\■■ ■■►\■■\OMEN ■'■tit■■■■e■■■■■ ■■■■.■■■■■e.■t■■■■.■■■■■a►■■■■■■.■■t/■ t■■■►■■ ■ ■■■■■■■■e■■■■■ CCCCCCCCCCCCCCCCCCCCCCCCCt\CCCi\"CC:: : ME C:CCCCCCC MCCCCC CCCCCCCCCCCCCCCCCCCC■'C CCCCCi►CCiiiICCCi'�'C'iiN■NE Ott■■■■■./'CCCm .tt■■t■itt■ CCCCCCCCCCCCCCCCCCCCCCCCC' Caiiiiiiii'CiCCCCCCCCC' MONSOONCMENOMMCC ■■■■■■■■■■■■■■■■■■■■■■■■■�■■■■■■■■■■■■■■■tu■.ttC ■■■■■■■.■■t■■■■■ ■■■■■■■t■■■■t■■■t■■t■.■tt/r/t■tt . 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