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P8114 Ken Hoots Ln DAVIE• COUNTY HEALTH .DEPARTM,E;NT IMPROVEMENTS .PERMIT AND.:CERTIFICATE 'OF. COMPLETION ` 'NOTE:Issued intompliance With Article II of G,'S.Chapter 130a._ fSa nary sew ge 7jems, ',; ;' Pertmit Number Name N20 Location ' _ r 1 l,,l �:',a f l �' •', ,c ! 7l { !�t: C 5` .c� /' f ��i� / 1�' f Subdivision.Name �I'' Lot.No., 'Sec. or-Block-'No.., Lot Size /�'1. _ House Mobile Home•_ --Business _- Industry No. Bedrooms, _-.No; Baths No. in Family _ Public Assembly, Other Garbage Disposal YES NO p - Speciflcatlons for System: y' Auto'Dish Washer YES NO. ❑ �, tr .,`c' f `. d>! ' - Auto Wash Ma^hine YES NO [] • ` �'' `� • ,t, Type Water. Supply - -- --- *This permit Void if sewage system described below is not installed within 5 years from date of issue. Thi s`permif is subiect to revocation if site plans.or the intended use change ATTENTION:'. YOUR SEPTIC SYSTEWCONTRACTOR MUST SEE THIS PERMIT/LAYOUT BEFORE INSTAWNG THIS SYSTEM. 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., l 1:00-1:30 P.M. or 4:30-5:00 P.-M.On' day of completioni4elephone Number: 704-634-5§O.$"60 Final Installation Diagram: y, y k S stem Installed b Certificate of'Completion' __ Date '��y� '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 N0 way be'takemas a guarantee that the system will function ,satisfactorily for any given period of time. I 114r wilt '9�. APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PE �OJ j�' Davie County Health Department t5 1J /}� Environmental Health Section ,/ P. O. Box 665 +» 5 1995 Mocksville, NC 27028 1. Application/Permit Requested By ��n tl 1 e Led-�o i,-cl Mailing Address P a o �-3 Home Phone 9 9)- 4'5 7 A clyancxe AC �j oo(o Business Phone (1,92- LILS 11�L 2. Name on Permit if Different than Above 3. Application for ❑General Evaluation Septic Tank Installation Permit 4. System to Serve: ❑ House 0 Mobile Home ❑ Place of Public Assembly ❑ Business ❑ Industry ❑ Other ❑ Unknown 5. If house, mobile home: Subdivision Section Lot # ❑ Basement/Plumbing No. of People 13 ❑ Basement/No Plumbing No. of Bedrooms 3 Er washing Machine No. of Bathrooms -21 C-6ishwasher Dwelling Dimensions 9 x 47 C>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 8. Property Dimensions 7 QGf-GS Sewage Disposal Contractor 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes 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: Go +o A c kd t,cc- (.lnde,-pcllss Rd - /-51- dr�,rG on l -F - K Noes L4 he. - ac.i-oss -Ae I"at 1lroad 4-r-octs - ),nd drive. arN IcI4 This is to certify that the information provided is correct to th a of my knowledge, and nderstand I am responsible for all charges incurre from this application. _ 3 -�s 'IA4 DATE 63S RE CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY MUST CHECK ONE: ❑ 1. 1 OWN the property. P 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 the Davie C unty He�Ith Qepartr�ent to enter upon above described property located in Davie County and owned by. A,5e-t $- gato r-�drlCral to conduct all testing procedures as necessary to determine said site's suitability for a ground absorption sewage treatment ,and disposal system. t� 3 ' ' DATE �—' SIGNATURE DCHD(1193) DAVIE COUNTY HEALTH DEPARTMENT 4 Environmental Health Section Soil/Site Evaluation NAME �i`f7l el DATE EVALUATED ADDRESS PROPERTY SIZE PROPOSED FACIILTY /t LOCATION OF SITE ��Lj�iu�4- .C/Y Water Supply: On-Site Well _ Community Public 41 Evaluation By: Auger Boring Pit Cut FACTORS 1 1 2 3 4 Landscape position L Sloe % 6Z HORIZON I DEPTH 1 Texture &roup Consistence Structure Mineralogy HORIZON II DEPTH t" y Texture group Consistence Structure Mineralogy : i 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 RATEJ q I SITE CLASSIFICATION: EVALUATED BY: . 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 <.-lay loam, SIL-Silty loam CL-Clay loam SCL-Sandy clay loam SC-Sandy clay SIC-Silty clay C-Clay CONSISTENCE Moist VFR-Vc..-y friable FR-Friable FI-Firm VFI-Very firm EFI-Extremely firm Wet NS-Non sticky SS-Slightly sticky S-Sticky VS-Very Sticky NP-Nonplastic SP-Slightly plastic P-Plastic VP-Very plastic Structure 3C-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 ■■■■■.■■■■■■■■■.■■■..■■■EM■■...■ .■.■.■.■■/N■■E■N■■■E■■■■■■■O■■■■ ■.■.■■■.■■■■N■■N■■■..■■.■/.■.■■...■■..O■■■NN■■N.■N■.NE■.O.■■.O■■■■ ■■..■■■/■■■.■.■.■■■■..■■■■.■■■.■.■./■■■■■■■■■■■■■.■■■■■■..■.MONO■■ ■..■■■■■■e■.■■e■■.■.■.■■■■.■■/■■■EMM■.NMN■ ■■■N■.N■ ■NMN■■MN■■N.■ ■■■N■■■■■■■■E■■■■■■■E■■N■■■■■■O■■■■■N■O■/■E■NNNNMom MOM■E■N■NON■■N ■.......■.■....■■..■...■■...■■■.�■ME■■■■N■.NN■■■■N E■.N■■EEM■N■■■ ■NOMMEN■■NN■■■■■■■...■.■■■■■.■■■ ■E■■M.■■N.■■■NE■■ -ON■MENEM NN■■ ...............■..■........�1■■■■■■■........mom.�■■.- soon_.....■.. ........................... ................... 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