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P7307 Keepa Way V`t.�.l R DAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION *NOTE:Issued in Compliance With Article 11 of G.S.Chapter 130a r-rob -Sa itar Sewage Sy-,�,teF,�s ��r��` Permit,,I�13u� tyer Name / „Date Location Ile �� ./f,_ Jj1 i, �',v /�'`!"i' /•=r'ii ' L('%J,�'s� i'`? • :✓S;.; ; !%%/�'. ,s�: .:_ „�f..j/I,�,i Subdivision Name ” Not 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 ❑ NO Auto Wash Ma;hive YES ❑ NO ❑ � iC X S','/,;� ' - i'f 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. TI 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 — 11 _ger ovdd r� Certificate of Completion / �!��t 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 satisfactorily for any given period of time. APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT --- 9io Davie County Health Department Environmental Health Section P. O. Box 665 C Mocksville, NC 27028 SEP 10 19 1. Application/Permit Requested By. o L��Y1•�'V I [� Vf� COUNTY HEALTH s' d Mailing Address 390 J!�rNCA0004 5-h�AJ- 'S,to4tk 430 LA",A-u, SAL... N.L -injo3'ie,3� Home Phone 71'4' 00(0y Business Phone ��• 5 d"'� 2. Name on Permit if Different than Above 3. Application/Permit for: ❑ General Evaluation Septic Tank Installation 4. System to Serve: ❑ House ❑ Mobile Home ❑ Place of Public Assembly ❑ Business ❑ Industry eOther DO& Kar4\AA_ ❑ Unknown 5. If house, mobile home: Subdivision Section Lot# ❑ Basement/Plumbing No. of People ❑ Basement/No Plumbing No. of Bedrooms ❑ Washing Machine No. of Bathrooms ❑ 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: ❑ Public &i-15rivate ❑ Community 8. Property Dimensions Sewage Disposal Contractor 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes $r90 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: h 1 riwt�- Lv s•w1-ti,nr. 8o I (?0 I✓ r-..L , L) .4 V CA,--) , uy—-0+� A; 44� 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 i application.141 <\J�C�� ATE/R SIGNATURE CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY Fanddisposal ECK ONE: Pell, 1 OWN the property. ❑ 2. 1 DO NOT OWN the property. ked Box#2, the rest of this form MUST be completed by the owner or a person authorized by the owner: ve consent to the authorized representativ of the Davig,County Health Department to enter upon above described cated in Davie County and owned by %oti•, t► I � all testing procedures as necessary to determine said site's suitability for a ground absorption sewage treatment system. Ln �., DA`TE SIGNATURE DCHD(12-90) 1 , DAVIE COUNTY HEALTH DEPARTMENT • Environmental Health Section Soil/Site Evaluation NAME lGl�"iY� DATE EVALUATED ADDRESS PROPERTY SIZE Z f-IA25-'. PROPOSED FACIILTY /�1Azky LOCATION OF SITE (1 O1�/h2 Water Supply: On-Site Well Community Public Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3 4 Landscape position 4.- Slope Sloe % HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH el 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: G /9G' EVAL ATED BY: LONG-TERM ACCEPTANCE RATE: A/ik/-OrER(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 ■.■......■■./■■■..■/.■/■■■■■■/■■ ■■/■.■/■...■/....■..e■■■/.■e■■■■ ■■■■./■....■■■.■■■■■■■■■■■.■./././■■/i....■i■......■....■..../MEMO ■■..■■■■......■■....■..■........ ..............■........■■....■.■ ■■..■......■.....■.■■.■■....■■■■..■..■..■ .i.■�.m..■■.. 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