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2496 Liberty Church Rd (3) x. DAVIE COUNTY HEALTH DEPARTMENT _ IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION t *NOTE:Issued in Compliance With Article 11 of G Sanitary Sewage yste Permit Number Names-� F. I� �i�' V ` � /, f Date /'-/ `/; N2 8106 Location — r' V, Subdivision Name Lot No. Sec. or Block No. Lot Size IA" _ House _ Mobile Home L!_ Business _— Industry No. Bedrooms _ No. Baths _Lr.�' No. in Family Public Assembly Other Garbage Disposal YES ❑ NO (El' Specifications for System: Auto Dish Washer YES ❑ NO ❑" / Auto Wash Ma^hine YES NO ❑ Type Water Supply 41) '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. Improvements permit by _ �Y *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: �"'' ^' �DC)i System Installed by T Certificate of Completion — 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 as a guarantee that the system will function satisfactorily for any given period of time. ' APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PER IS ti Davie County Health Department Environmental Health Section P. O. Box 665 " 5 Mocksville, NC 27028 1. Application/Permit Requested By " `,,� Mailing Address Home Phone 764/--</9i 2—.$r-288 G J S S' Business Phone 2. Name on Permit if Di Brent than Above 3. Application for: ❑General Evaluation � Septic Tank Installation Permit 4. System to Serve: ❑ House Ltd'/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 2 ❑ Washing Machine No. of Bathrooms / Y2- ❑ Dishwasher Dwelling Dimensions X 74) ❑ 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 Ep'/Private ❑ Community 8. Property Dimensions Sewage Disposal Contractor 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes VNo 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: 6 0/ Ale 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 this application. -� /9 S DATE SIGNATUFIE CONSENT FOR SITE EVALUATION TO BE DONE gN ABOVE DESCRIBED PROPERTY MUST CHECK ONE: 20"l. I 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 qf,t he Davie CounN Health D part ent to enter upon above described property located in Davie County and owned by -.kfU41n&1a-4.. Lle 44J.(& A to conduct all testing procedures as necessary to determine said site's suitability for a ground absorption sewage treatment and disposal system. 4u,4� !V ATE SIGNATURE DCHD(1/93) .t .y DAVIE COUNTY HEALTH DEPARTMENT ` Environmental Health Section Soil/Site Evaluation NAME DATE EVALUATED ADDRESS PROPERTY SIZE �14<& PROPOSED FACIILTY LOCATION OF SITE Water Supply: On-Site Well _ Community Public Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3 4 Landscape position 1. Sloe % HORIZON I DEPTH Texture group Consistence Structure 'MineralogX HORIZON II DEPTH JI/' Texture group G Consistence rr Structure Mineralogy 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: EVALUATED BY: LONG-TERM ACCEPTANCE RATE: 1 OTHER(S) PRESENT: REMARKS: 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-V!---y friable FR-Friable FI-Find 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/ftz DCHD(01-901 CCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCI°�°CCiCCCCCCCCCCCC■CCCCCCCCCCCCCCC� ........................... ................... .... ............. ..■..■...■■..■■...................■..... 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