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P7667 Daye Ln DAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION *NOTE:Issued in Compliance With Article 11 of G.S.Chapter 130a Sanita Sewage Systems 4� q Permit Number Name S _ Date _ 35 �-� 1 y N2 7 6 6 7 Location Subdivision Name Lot No. Sec. or Block No. Lot Size_ 5 'Houser Mobile Home Business _— Industry No. Bedrooms —Ao., Baths,— _ No. in Family _ Public Assembly other Garbage Disposal YES ❑ NO c[ ` �.:. _Specifications fors;System: Auto Dish Washer YES NO ❑ , Do.o } q, Auto Wash Ma shine YES [ NO ❑ 3 0U, �tl r. x J� 1 s . 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. p w. 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., 1:00-1:30 P.M.or 4:30-5:00 P.M.on day of completion.Telephone Number:704-634-5985. Final Installation Diagram: System Installed by _ 0 foo `w 7 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. APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT Davie County Health Department Environmental Health Section P. O. Box 665 Mocksville, NC 27028 1. Application/Permit Requested By 0 �- Mailing Address P(D �� Home Phone 5;)S L cle""e A� JA�iv6g, N. G , 70G� Business Phone 16V 2. Name on Permit if Different than Above 3. Application for: ❑General Evaluationeptic Tank Installation Permit 4. System to Serve: ❑ House 0'1Vro-bile Home ❑ Place of Public Assembly ❑ Business ❑ Industry ❑ Other ❑ Unknown 5. If house, mobile home: Subdivision Section Lot # ❑ Basement/Plumbing No. of People 7 ❑ Basement/No Plumbing No. of Bedrooms ashing Machine No. of Bathrooms ishwasher Dwelling Dimensions Z04941 ❑ 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: ub�liic ,—y� ❑ Private El Community 8. Property Dimensions � L� ZSy Sewage Disposal Contractor r IVA( 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? El Yes t�'No If yes,what type? 'NOTE: Improvemeq!g-Re;mit.5 Improvements—ms all be valid for a period of 5 years from date issued. Improvements Permits are subject to r at' , if site plans or the intended use change. Effective October 1, 1989. Directio s to Property: r a This iAoe fy that theinformation provided is correct tot t of m e, and I understand I am responsible for all charges incurthis r -application. `� � : -- DATE SIGNATURE CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY MUST CHECK ONE: . 1 OWN the property. DO NOT OWN the property. If you checked Box #2, the rest of this form MUST be completed by the owner or a person authorized by the owner: I hereby give consent to the authorized representative of the Davie County Health Department to enter upon above described property located in Davie County and owned by to conduct all testing procedures as necessary to determine said site's suitability for a ground absorption sewage treatment and disposal system. DATE SIGNATURE DCHD(11W) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation NAME �� B U \1s DATE EVALUATED ADDRESS S A r�-,- PROPERTY SIZE ) 3-0 , x IS-61 S-61 PROPOSED FACIILTY �Ks, LOCATION OF SITE Aye `(fit Water Supply: On-Site Well Communi y Public Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3 4 Landscape position 1' S Sloe Z e - -0 4 ' v ��" 720 HORIZON I DEPTH Texture group 01 L �_L• Consistence Structure L Mineralogy1 . HORIZON II DEPTH Texture group Consistence =t 1 Structure S S k S Mineralogy ' ► 1 ' HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS S S RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION ,S •S S LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: ��S EVALUATED BY: LONG-TERM ACCEPTANCE RATE: '� OTHER(S) PRESENT: REMARKS: XX 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 :lay 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 watei* 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 ..................■........................... ........ .......... .........................................�....:.■......:..■.... .. ......................................... .....................I■■ .................................................................. ................................ ............................■■■. ■■■/..■./...■■///.../.......■..■ ■////..■. ■.■...■■■.....■.■. 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