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122 Laird Rd DAVIE COUNTY HEALTH DEPARTMENT F70 -vo.a�.9. IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETIONa ;c •NOTE:Issued in Compliance With Article II of G.S.Chapter 130a x Sanitary Sewage Systems_ Permit Numbero Name �, , .� �_ \ _ ' _--Date L� N2 8 210 Location Subdivision Name Lot No. Sec. or Block No. Lot Size i `/ House _ Mobile Home ---_ Business -- Industry No. Bedrooms --'—.No. Baths — -- No. in Family , _ Public Assembly Other Garbage Disposal YES ❑ NO [f Specifications for System: Auto Dish Washer YES ❑ NO CD/ ,r„ Auto Wash Ma^hine YES C�� NO ❑ � " `? fjcJ ' 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. ATTENTION: YOUR SEPTIC SYSTEM CONTRACTOR MUST SEE THIS PERMIT/LAYOUT BEFORE INSTALLING THIS SYSTEM. iV `y , 1 j f=� Improvements permit by ----'- w *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: t�t t` , System Installed by D r J , 1J Certificate of Completion �_ > _ Date ID '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. t@L5 � V LS APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMI I D Davie County Health Department Environmental Health Section SEP 12 P. O. Box 665 Mocksville, NC 27028 1. Application/Permit Requested ByTb� J Mailing Address Home Phone l©� U c 70 2 Business Phone 2. Name on Permit if Different than Above 3. Application for: U"General Evaluation ❑Septic Tank Installation Permit 4. System to Serve: ❑ House 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 JP-Washing Machine No. of Bathrooms hh� ❑ Dishwasher Dwelling Dimensions oC g 40 ❑ 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 I No. of Water Coolers No.of Showers \ Water Usage Figures 7. Type of water supply: [X Public �( ,�� 4t El Private El Community 8. Property Dimensions AFI X A� /l I&S Y-50 Sewage Disposal Contractor 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes XNo 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: 158 -6 RC&IO-VIOL (.hi•(.r 'l 0 , J u,rN 0 AJ iMt 9bU �vme� 4U bJa�,�- mal fax U)/)4c � n vrt. e vs ) 1 to 14- s t woodeot Vc ear& This is to certify that the information provided is correct to the best o(7 n ledge, and I understand I a e ponsible for all charges incurred rom this application. _ -/x—'73WM F,- — rn v DATE SJONATURE CONSENT FOR SITE EVALUATION TO 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 MUSTFeo pleted by the owner or a person authorize by the owner: I hereby give consent to the authorized representate Davie C!n HekMDfpartrnt to ent upon above described property located in Davie County and owned by to conduct all testing procedures as necessary to de i e said site's uitability for group absorption sewage treatment and disposal system. —� DATE SIGNATURE DCHD"(1/93) i DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation NAME DATE EVALUATED ` '"' ADDRESS 4'V.�A``'0" PROPERTY SIZE 4s-�1 qlU�' D' PROPOSED FACIILTY LOCATION OF SITE Water Supply: On-Site Well _ Community Public Evaluation BYV& Auger Boring Pit Cut FACTORS 1 1 2 3 4 Landscape position -S S Sloe % _ .6 HORIZON I DEPTH t' hLo Is Texture groupQ L C V 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 S S_5 .SS 5:S RESTRICTIVE HORIZON l SAPROLITE CLASSIFICATION .S LONG-TERM ACCEPTANCE RATE r• SITE CLASSIFICATION: 14 J " 1 EVALUATED BY: �`- 1b LONG-TERM ACCEPTANCE RATE-- a L4 Q OTHER(S) PRESENT: ID 'r"sREMARKS: '4 `� a. cx3� _1� A LEGEND Landscape Position R-Ridge S-Shoulder L-Linear slope FS-Footslope 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.ry 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 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 ■■■■.■■■/■■■■■■.■■...■■■■■■/■■.■■■■■■■■■■■■■■■■■.�■■■■.■■■ SSSS■■■ ■■■■■■■■■■■■■■.■■.■■■■■■■■■■■■■■M■■■■■M.E■ME■MM■MSE ■.■■■■■■.■■■■ ■■■/■■■■■■■■■■■■■■■■■.■■/■■ SSSS■■/■■/■ SSSS■■■ /■■■ SSSS .■■■SEEM OMEN MMMMMMMMMMMMM ■■■E■■■■■■M■S■■■■■■■■■■■■■■■■■■■..■■■S■■■■■■■S ■.E■SSHr■■S■■■■■■ ■■S■■■E■■■■■■.SSS■■■■■■■■.■■.■M■■■■■■S■S�SMSC�MMSCMEMC M.MEM■ on ■■■■■■■■■■■■.■■■■■■■■■/■■■■■■■■■..E.M■■■ ■■■ ■ M ■■M ME■■■■■M ■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■..■u�■■E■■SME�MEMMMMEMEM■..■■.M.■MMM■ SSSS■■./SSSS/■■■■■■■■■■■■.■■■■■ SSSS■■■N■MS■■■E■S■■■SS■■■S■S■■■ MMMMMMMMNMM mom CCMCMMMMMM:SMMMCCMMCCMMMMMMMCMCMCCMM'MNMC:IiCC■CMC "■■MEMMEME■SM ■■..■■■■■■■■■ME■SSE.■■■E■ME■EM■■EM MCS■.SMS �IM■N■ME.M.EM. 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Based upon the information provided op the application for site evaluation and after the evaluation was completed, the site was found to be provisionally suitable for the installation of an on—site sewage disposal system. If you have any questions, please feel free to contact this office. Sincerely, Charles E. Little, R.S. Environmental Health Section CL/wd Enclosures) I ti f i i 1