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1091 Joe Rd �* - r 7e.s.,t DAVIE COUNTY HEALTH DEPARTMENT —_— �[ IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION MOTE:Issued in Compliance With Article 11 of G.S.Chapter 130a . Sanitary/.Sewage Systems Permit Number Name�l� �, / / 1• _ Date ��" - No 7363 'At "Location 1/.f g r���� b` c?P 0,/ L�— dr- Subdivision Name Lot No. Sec. or Block No. r Lot Size House Mobile Home �� Business -- Industry No. Bedrooms--? No. Baths n No. in Family �— Public Assembly Other Garbage Disposal YES ❑ NO 2'' Specifications for System: ` Auto Dish Washer YES ❑ NOfJ ./sr - Auto Wash Ma-.hive YES [ NO ❑ 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. M• �o cam. a 1. Improvements P y 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.Telephone Number:704-634-5985. Final Installation Diagram: System Installed by 4 r _ p3 Certifi to of Cynpletion Date - + 'The signing of this certificate shall indicate that the systaqv 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 ;iry `ED Environmental Health Section P. O. Box 665 N Q V — 01933 Mocksville, NC 27028 1. A lication/Pe Re uested B Mailing Address '_nL ,)� Home Phone C e Busl s 2. Name on Permit if Different than Above 3. Application for: ❑General Evaluation lySeptic Tank Installation Permit 4. System to Serve: ❑ House 03'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 3 ❑Washing Machine No. of Bathrooms a c� ❑ Dishwasher Dwelling Dimensions /I /��/ 6y ? ❑ 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 r 1 8. Property Dimensions A� `Jr Sewage Disposal Contractor 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes 91-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: 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. �� - T -9 3 — Ao— ±-PALZ-� ) 'L-&- DATE SIGNATURE CONSENT FOR SITE EVALUATION:E-Q BED NE ON ABOVE DESCRIBED PROPERTY Fanddisposal ECK ONE: �I OWN the property. ❑ 2. I DO NOT OWN the property. ked Box#2,the rest of this form MUST be complet9d 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 system. DATE SIGNATURE WHO(1(93) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation NAME ftO 1�� DATE EVALUATED ADDRESS PROPERTY SIZE G PROPOSED FACIILTY LOCATION OF SITE : SID e �!J Water Supply: On-Site Well Com-nunity Public . Evaluation By: Auger Boring Pit Cut } FACTORS 1 1 2 3 4 Landscape position Slope Z HORIZON I DEPTH i. '� �� •� Texture group Consistence Structure Mineralogy HORIZON II DEPTH Texture group Consistence Structure / Mineralogy HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE .� SITE CLASSIFICATION: Ac EVALUATED BY: LONG-TERM ACCEPTANCE RATE: 7 OTHER(S) PR SENT: REMARKS: Q04 ���� &0_5' �%1l��Iiit�e�� `-- Q /•�i¢v� byell 4.1i 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 "CL-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 Mineraloer 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 chrome 2 or less Classification S(suitable), PS(provisionally suitable), U(unsuitable) LTAR - Long-term acceptance rate - gal/day/ft2 DCHD(01-901 ................................................ ............. ... .................................................................. ............................................................... .. ■■■■.■M■�.■■■���/■■■■■■■■■■■■■■■■■■■■.■.■■■ MUMU ■ ■ ■■■ C■■■■■■ ■■ ■.■..■...1...�I/.■■■.....■■■■■■■■■■■■■■■■.C■■.. .COC■■MC■■.■M■■CCM■ ■■■■■■■■L'.Gini:■■■■■.M..■■.■■■M■■■■■.■■.■■■■■■■■■■■■■■■■■■.■■■■■■■■ CCCCCCCCCCCCCCCCCCCCCCCC:iCCCCCCCC'CCCCCCCCCCCCCC'=CCCCCCCC:MCC:C ■..............■.....■..■....■./.■../■.■..■......./■ ■U■■■■■■■ ■.■ ■/■/..■■..■.■■..■.■■■/■■.■/■■/■■ ■./.■■■■■ ...■.....E.■......C■■m ■.....■■M■■.■■M......N..■..e■.....■.■.■.■■■■■■■/■■■■C■■■r■■.ME■rC CCC:.C'CCCCCCCCCCCCCCCCCCCCCCCC'.:CCCC:.:CCCCCC':�=NONNCCCC'CCC ...........................■■■e■■.■■■■M■■.■O■■.■■■CMEMEMMEMMECmom CCCCCCCCCCCCCCCCCCCC��CCCCCCCCCCCCCCCCCCCCCCCCCCCCCCC.■=C■C.■Cr■ CCCCCCCCCCCCCCCCCCCCC�CCCCCCCCCiCCCCCCCCCCCC�'CC:'CCC'CC CCMCCCC' ■................■■............■..■MO■■■.MMM..C��WOMEN C=N�E■M■MM■ ■■■■.■■.■■■■■■■■.■■■ ■■■■■■■■■■ ■■■■■.■■■■r■■■ rAa■■■■ MUMU■■■ CCCCCCCCCC■:C■�C■:CCCC:CCCCC:CCCCCCCC' CMIEN CC:CCCCCC CCCCCC■ ■.■■■■■■■■■■■■_.■■■■E■■■■■.■■M■■■■■■.■■� MEMO EARN■CM ■■■■■■ UNMEMMCuCCCC.C�3CCCCCCCCCCCCCC CCCC MOMMU C'CCC■ CCC'ME """"""'��"""""""""""" CC1■�C Ni.CCON Cii■CC.0 ■.■■■.■■■■■■■�■■■■■■■■■■■■■■■■.■■■.■■■C■■ ■C ■ ■MUMU.■ NNW ON .......■.■■M■��r..■■M■.■■■■M■M■■■..... ...■ -MENo MEMMAI M■■MEC. 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