326 Jack Booe Rd (2) % - DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTEAssued in Compliance With Article II of G.S.Chapter 130a
Sanitary Sewage Systems j�,l,�/ Permit Number
Name '^
Location
Subdivision Name Lot No. Sec. or Block No.
Lot Size _ House Mobile Home Business __ Speculation
No. Bedrooms No. Baths - No. in Family
Garbage Disposal YES ❑ NO [ Specifications for System:
Auto Dish Washer YES p NO
Auto Wash Ma shine YES NO ❑ ��`
Type Water Supply 1)-4
*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.
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Improvements permit by _� Z
*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.
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85 `
Final Installation Diagram: System Installed by ��!/,J
J ,v
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G
Certificate of Completiopa�� Date _
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'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 PE M
Davie County Health Department
Environmental Health Section
P. 0. Sox 665 11199
Mocksville, -NC � 27028
1 . Application/Permit Requested By /I
Mailing Address G 1`Z
Home Phone Business Phone
2. Name on Permit if Different than Abovet-Q
3. Property Owner if Different -than Above --
4. Application/Permit For: 0 General Evaluation �ank Installation
5. System to Serve: 0 House � �bile Home 0 Business
L Industry u Other 0 Unknown
6. If house, mobile home: Subdivision Sec. Lot#
No. of People "3 Dwelling Dimens , ons
No. of Bedrooms � Basement ,P umbing
No. of Bathrooms Base ent No Plumbing
Washing Machine J Dishw her 0 Garbage Disposal
7. If business, industry, other: Specify type
No. of People Served No. of Sinks 1
No. of Commodes No. of Urinals n
No. of Lavatories _ No. of Water Coolers )
No. of Showers
8. Type of water supply: w/public 0 PrivateCommunity
9. Property Dimensions
10. Sewage Disposal Contractor _
11 . Do you anticipate additions/.expansions of the facility this system is
intended to serve? 0 Yes 40
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 the
best of my knowledge, and I understand I am responsible for all
charges
rincurred from this applicati n. /
L-t
Date Signature
Directions to Pr7V4
rty •
57' , � , C)k J-7L
F6 (� GoA
DCHD (10-89)
DAVIE COUNTY HEALTH DEPARTMENT
;. Environmental Health Section
Soil/Site Evaluation
NAME Alf�7i��rs _ DATE EVALUATED
ADDRESS PROPERTY SIZE CD/9�
PROPOSED FACIILTY LOCATION OF SITE 3/•e y 1
Water Supply: On-Site Well Community Public
Evaluation By: Auger Boring � Pit Cut
FACTORS 1 , 2 3 4
Landscape position S S'
Slope %
HORIZON I DEPTH
Texture group
Consistence
Structure
MineralogX
HORIZON II DEPTH 17 — /aC 7 -�
Texture group
Consistence
Structure
Mineralogy
HORIZON III DEPTH
Texture grOu2
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE /
SITE CLASSIFICATION: G EVALUATED BY: �/� l�/
LONG-TERM ACCEPTANCE RATE: / 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
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
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