158 Kayla Trail (2) 64
DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
NOTE:Issued in Compliance With Article II of G.S.Chapter 130a
Sanitary Sewage Systems Permit Number
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Name c'r^
r-ate ND
7 9
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"I Locations '�;: %/ Z ✓ L' t`-"� i —fr :i - `f '/ r, G�� :z.�C1/
Subdivision Name Lot No. Sec. or Block No.
Lot Size %=�� t. _ House — Mobile Home ---_ Business _— Industry
T✓' ��/iti 7
No. Bedrooms . ZJ .No. Baths No. in Family — Public Assembly Other_
Garbage Disposal YES ❑ NO [. '� Specifications for System:
Auto Dish Washer YES ❑ NO
Auto Wash Ma^hine YES ❑ NO
Type Water Supply —� `lf /�_----- ---
'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
ATTENTION: YOUR SEPTIC SYSTEM CONTRACTOR MUST SEE THIS PERMIT/LAYOUT BEFORE INSTALLING THIS
SYSTEM.
S�
J'
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 — iir>1/Ii� ��,4.
i�
Certificate of Completion -- Date —x?
S
'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.
pPERMIT _
fl . APPLICATION FOR SITE EVALUATION/IMPROVEMENTS
Davie County Health Department >✓c� l nqqf Environmental Health Section ,,, 'P. O. Box 665 im"
Mocksville, NC 27028 (�
VVV
1. A licati n/Permit Requested B 1��( N ` 061 NSON
PP 4 Y I _
Mailing Address 171(. gra� � D(2fy L Home Phone
W(N SMON —_' 4AVA N G a7 I v G Business Phone I 7.7 �5 O
2. Name on Permit if Different than Above
3. Application for: General Ev luation Septic Tank Installation Permit
4. System to Serve: /.�PrA) ❑ Mobile Home ❑ Place of Public Assembly
❑ Business ❑ Industryy 0 ❑ Other ❑ Unknown ;
5. If house, mobile home: Subdivision No Section Lot #
❑ Basement/Plumbing
No. of People 0 Basement/No Plumbing
No.of Bedrooms L El washing Machine
No.of Bathrooms Dishwasher
Dwelling Dimensions A$OvT 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 M Private ❑ Community
8. Property Dimensions 42 ��fES Sewage Disposal Contractor
9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes Z 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:
IaCG $0 'vi el
4;4, c— G C, .
V", L,�_ f'`l is `�O W l� v� t�,rc v C Ci�/1
IOD I� a, ' +?ALIS
P �
This is to certify that the information provided is correct to the best of my knowledge, and I understand I am responsible for rill charges
incurred from this aapppl' ati n.
- / 1
DfA
TE SIGNATURE
ON E T FORISITTE EVALUATION TQ BE DONE ON ABOVE DESCRIBED PROPERTY
MUST CHECK ONE: ❑ 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 representative of t e6 County Health Dep ment to enter upon above described
property located in Davie County and owned by = � ' ✓L l l G21�T
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'(1/93)
i '
DAVIE COUNTY HEALTH DEPARTMENT
Environmental _Health Section
Soil/Site Evaluation
,7US DATE EVALUATED 2-9/
S PROPERTY SIZE
POSED FACIILTY '44 LOCATION OF SITE
Water Supply: On-Site Well Community Public
Evaluation By: Auger Boring 7/ Pit Cut
FACTORS 1 2 3 4
Landscape position 2-
Slope
Sloe % a
HORIZON I DEPTH Z
Texture group 1,4l�C
Consistence
Structure
Mineralogy
HORIZON II DEPTH
Texture groupC'
Consistence
Structure AhAl
Mineralogy ( P
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
_ 6% r�
SITE CLASSIFICATION: _2)T-611V�Vr C \✓D EVALUATED BY:
LANG-TERM ACCEPTANCEI�ATE: OTHER(S) PRESENT:
REMARKS: 'e-e �
LE END
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 Vcry 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(prdvisionally suitable), U(unsuitable)
LTAR - Long-term acceptance rate - gal/day/ft2
DCHD(01-901
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Davie County Yfeaff De artment
and .Moine Yfeali§ Ayemy
210 HOSPITAL STREET/P.O.BOX 665
MOCKSVILLE,N.C. 27028
PHONE:(704)634.5985
August 1, 1994
Mr. Kevin Robinson
1716 Brookwood Drive
Winston-Salem, N.C. 27106
Re: Site Evaluation
Wesley Chapel Rd./Barn
Dear Mr. Robinson:
As requested, a representative from this office visited the aforementioned
site on July 27, 1994. Based upon the information provided on the application
for a site evaluation and after the evaluation was completed, the site was
found to be provisionally suitable for the installation of a modified,
oversized on-site sewage disposal system.
If you have any questions, please feel free to contact this office.
Sincerely,
Robert B. Hall, Jr., R.S.
Environmental Health Section
RH/wd
Enclosure