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326 Jack Booe Rd ,ww---P- - -• '. •L- s•-Y�•�rsv. -- ---w-+v-,--.+....�.. xn- -- r �1p 4�• - ate, �I " v`J� r rtw DAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENTS*PERMITiI�AND CERTIFICATE OF COMPLETION - 'NOTE�Issued in Compliance With Article II of G.91.Chapter 130a R _ _•Sanitary Sewage Systems � ' ' Permit Number Name � �s ,rte y ac � ISG ` *.Date 1 _. 1142 8053 NOLocation - .? I .: *� � ,� •` .11� s Lo c) 1 .,, ca c.' � <_` . # 'I _ Subdivision Name L'ot No. Sec. or Block No. �_ Lot Size _ House _ Mobile Home _—_ Business __ Industry No. Bedrooms: � '—.No.'Baths ="_— No ?n;Family — �Public Assembly Other Garbage Disposal., t YES p NO C �• ' a Specifications forA System: Auto Dish Washer YES p NO Auto Wash Ma^hine YES Be NO. Type Water Supply y—_=-- J •'This permit Void if sewage system described'below4is''not installed within 5 years from date of issue.. This permit is subject to revocation if site plans ori the intended use•charige . ATTENTION; YOUR SEPTIC SYSTNTSACTO MUST SEE TRIS PERMIT/LAYOUT BEFORE INSTALLING THIS SYSTEM. ti'! If 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., 1:00-1:30 P.M. or 4:30-5:00 P.M.on day-of completion}9+TetephoneNumber: 704-634-5985. Final,tnsfallation Diagram System Installed by 1 �` Certificate ofCompletion Date,. 'The signing of tfi'i certifi r l •` ,'' g g s cafe shal .indicate that the', described,above has been'installed .in .compliance with `the standards set forth in the above regulation, but shalt in•NO way,be taken as-a guarantee that the system'will function satisfactorily for,any given period of time. ��I A APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PER Davie County Health Department Environmental Health Section MAY 3 0 10 P. O. Box 665 Mocksville, NC 27028 ENVI�AVIE�ENTUL HEA11H . 1. Application/Permit Requested By r / Mailing Address Home PhoneZ as 97 71Business Phone 2. Name on Permit if Different than Above 3. Application for: 0 General Evaluation ��/ UYSeptic Tank Installation Permit 4. System to Serve: ❑ House A Mobile Home ❑ Place of Public Assembly ❑ Business ❑ Industry ❑ Other ❑ Unknown 5. If house, mobile home:Subdivision Section Lot # ❑ Basement/Plumbing No. of People �� ❑ Basement/No Plumbing No. of Bedrooms fishing Machine No. of Bathrooms �n ❑ 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: 'ublic ❑ Private ❑ Community 8. Property Dimensions ) Sewage Disposal Contractor 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes pfo 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: This is to certify that the information provided is correct to the best of my knowledge, and I understand I am riasponsible for all charges incurred from this aplication. , / DATE SIGNATURE CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY MUST CHECK ONE: 06 1. 1 OWN the property. ❑ 2. 1 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 representativ f the vie Coun H e ent to enter upon above described property located in Davie County and owned by % to conduct all testing procedures as necessary to de rmine said site's suit ility for a ground sorption sewage treatment and dispo71system. . / a DATE WINAZT=URE DCHD(1/93) Na DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section o ) Soil/Site Evaluation NAME Wp`5 a N V" �Y �t)tc_�Ot.)_s DATE EVALUATED ADDRESS S A trc•-e PROPERTY SIZE PROPOSED FACIILTY � . )A0 TX"-'q LOCATION OF SITE � IRA Water Supply: On-Site Well _ Community Public Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3 4 Landscape position Sloe Z - o )-9-16" HORIZON I DEPTH � Texture group L L Consistence F Structure R Mineralogy HORIZON II DEPTH 1 Texture groupC Consistence F Fz� Structure C Mineralogy HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS S S RESTRICTIVE HORIZON -- SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: '� EVALUATED BY: LONG-TERM ACCEPTANCE RATE: a L4 OTHER(S) PRESENT: REMARKS: �_ I LEG ND 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 3C--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 watet' 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 ■...■..■■■■■Mes..■■/■.■.....■■.■ ■■/.....■/M./NM//E//.eM.M■■/.//■ ■..■■■.■■■/■/■■.■/■.■.■■./....■■.....///■.../■■■■■.//■■./■.■■./■./ ..................■........�.................■._.■. _...._.■.OMMEM ■■■■ ■■N. ■■.■.■■..M■■■■■SMR■S■./SMS■ ■■■/.■...■.■.■■.■.. ...SME.■ ■....■..■.e....■■..M■tM/M.■■.t■■...■...■■.t... ■NEENNI- ..■E%■.If. 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