P6166 Juney Beauchamp Rd N
DAVIE `COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTA:Issued in Compliance With Article I I of G.S.Chapter 130a -
Sanitary Sewage Systems 2 Permit Number
Name te --� Date f N2/ 6 1 6)s
Location /s' &9 .'�-��-�f�'.�F�%.� f tIr` �.J _),' n �` l i� >� 4
11
Subdivision Name Lot No. Sec. or Block No.
Lot Size / House 1-'' Mobile Home _ Business__ Speculation
No. Bedrooms _ No. Baths —t — No. in Family _
Garbage Disposal YES ❑ NO ❑ Specifications for. S stem: J
Auto Dish Washer YES [:] NO ❑ ,Y
Auto Wash Machine YES ❑ NO ❑ jj
Type Water Supply ---
*This permit Void if sewage system described below is not installed 1vit�thin 5 years from date of issue.
This permit is subject to revocation if site plans or the intended use ch�a ge.
a
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: System Installed by
kuEN '
log'
oma.
� Da yN
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
satisfactorilyfor any given period of time.
/ of >< e v ua ion
NAME A1yx ' DATE EVALUATED
ADDRESS G y,?1J/7'D�'S' PROPERTY SIZE
PROPOSED FACIILTYLOCATION OF SITE �C'l
Water Supply: On-Site Well Community Public
Evaluation By: Auger Boring !/T Pit Cut
FACTORS 1 1 2 3 4
Landscape position
Sloe % .1Z y
HORIZON I DEPTH G /�
Texture rou L 3'� XX S-4-
Consistence
4Consistence
Structure
Mineralogy
HORIZON II DEPTH -3a X-V 1
Texture group e
Consistence 41r-
Structure s4 .6
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 �o.2-
SITE CLASSIFICATION: J' EVALUATED BY: �f
LONG-TERM ACCEPT NC RATE: y 0 HER(S) P ESENT:
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
Mineralolty
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
HD(01-901
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+'APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department
u
Environmental Health Section
P. 0. Box 665
Mockaville, NC 27028
1 . Application/Permit
�Requested By �! T
Mailing Address /`� K&--SL?-z
Home Phone Business Business Phonf,4f,7•�/-?-
2. Name on Permit if Different than Above
3. Property Owner if Different than Above
4. Application/Permit For : General Evaluation 01"S/Tank Installation
S. System to Serve: r7�H0uae L] Mobile Home (] Business
Industry u Other 0 Unknown
6. If house, mobile home: Subdivision Sec. Lot#
No. of People Dwelling Dimensions
No. of Bedrooms 7Basement/Plumbing
No. of Bathrooms ' _ Basement/No Plumbing
lashing Machine F Dishwasher �j Garbage Dispusai
7. If business, industry, 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
S. Type of water supply: V Public 2--grivate Q Community
9. Property Dimensions
10. Sewage Disposal Contractor
11 . Do you anticipate additions/expansions of the facility this system is
intended to serve? Yes igeflo,
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/ rovided is correct to the
best of my knowledge, and I understand I m responsible for all
charges incurred from this applicat o
Date Signature
Directions to Property :
P
d�
DCHD (10-89)