P6174 Lat Whitaker Rd DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
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*NOTE:Issued in Compliance With Article I I of G.S.Chapter 130a
Sanitary Sewage Systems / Permit Number
Name „�; ,��,-•i;✓, �Jn l" J;! f% lam/Dyate / -�ir� - 5l NO G174
Location
Subdivision Name �! Lot No. Sec. or Block No.
Lot Size,, ' %' 2�' House Mobile Home_�''` Business Speculation
No. Bedrooms No. Baths No. in Family _
Garbage Disposal YES ❑ NO p--"
Specifications for System: �/-
Auto Dish Washer YES NO ❑
Auto Wash Machine YES NO ❑ rC fy ; ,
Type Water Supply e: l�-�-� _--
*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.
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 1` Cl( ►`��{
411
Fy�
Certificate of Completion t`- Date
"The signing of this certificate shall indicate that the system descri ed 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
Davie County Health Department
Environmental Health Section
�I R O. Box 665
Mocksville, N.C. 27028
CONST, JCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone ZEE 9�IVQ
Permit Requested By Business Phe
2: Address 6
3. Property Owner if Different than Above
Address
4. Permit To: a) Install -✓Alter Repair
b) Privy Conventional 'Other Type
M p Ground Absorption
L
C)&�b-lZiacts+err � 'a 966._ Lot No. SQ 1.3
5. System used to serve what type facility: House Mobile Home Bs
Industry Other
b) Number of people T
6. a}If house or mobile home, state size of home and number of rooms.
House Dimensions_
Bed Rooms- Bath Rooms Z- Den w/Closet
b) If Business, Industry or Other, State: Number of persons served
What type business, etc.
Estimate amount of waste daily (24 hours)
7. Number and type of water-using fixtures:
commodes 2 urinals garbage disposal
lavatory Z showers y washing machine
dishwasher sinks
8. a) Type water supply: Public Private Community
b) Has the water supply system been approved? Yes ✓ No
9. a) Property Dimensions /-0 7(oA LQ
b) Land area designated to building site
c) Sewage Disposal Contractor
10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve? �—
What type?
This is to certify that the information is correct to the best of my knowledge.
to./r'- 9a C'
Date Owner SignaturIV
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
{AT W,4;it,
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DCHD(6-82)
DAVIE COUNTY HEALTH DEPARTMENT
001r
Environmental Health Section
Soil/Site Evaluation �,,
NAME t'�/!�!/�/ DATE EVALUATED �D/ ``l!
ADDRESS PROPERTY SIZE �ylZl�
PROPOSED FACIILTY
.fi►�1' LOCATION OF SITE
�
Water Supply: On-Site Well Community Public
Evaluation By: Auger Boring � Pit Cut
FACTORS oj�,_
2 3 4
Landscape position t�
Sloe 7. 41
HORIZON I DEPTH G
Texture group 5-- V-4_ T<
Consistence
Structure
Mineralogy
HORIZON II DEPTH
Texture group
Consistence
Structure
Mineralogy 4. i
HORIZON III DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION S, -
LONG-TERM ACCEPTANCE RATE
SITE CLASSIFICATION: Y 5 EVALUATED BY: X"Z,z
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 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-Finn 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
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