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3614 Hwy 158 .T =:�hV `Y ✓'y O DAME COUNrf HEALTH DEPARTMENT 1 Dori"t,n '- IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION .w -*NOTE:Issued in Compliance With Article 11 of G.S.Chapter 130a a;744G Sanitary Sewage Systems _ q Permit Number -Name ��..r �,. -- _ Date �- - ! �-} N® 7418 Loc t Subdivision Name v� Lot No. Sec. or Block No. Lot Size 5 House Mobile Home Business Industry No. Bedrooms No. Baths No. in Family _ Public Assembly Other Garbage Disposal YES Ef NO ❑ Specifications for System: Auto Dish Washer YES a NO ❑ J000 Auto Wash Ma thine YES pl NO ❑ Type Water Supply _ -'N" --- *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. • IV 0• 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., 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: System Installed by .r 140 U .S 1 , +J 3a r x Certific a of Com e'S on Date 'The signing of this certificate shall indicate th t the syst m descri ed-above has been installed in compliance with the standards set forth in the above regulation ut shall i NO wa taken as a guarantee that the system will function satisfactorily for any given period of time.-w , APPLION FOR SITE EVALUATION/IMPROVEMENTS PERMIT / Davie County Health Department 3 b X0 Environmental Health Section P. O. Box 665 1' Mocksville, NC 27028 1. Application/Permit Requested By L1eocae ( Je(ob Mailing Address 2+. 1 15ox 74 Odua.,oce,, A.).C. 09700ro Home Phone 6'3'4 Business Phone 2. Name on Permit if Different than Above Geo rye C4,�.M e C,Jelo b 3. Application for: d General Evaluation C"Septic Tank Installation Permit 4. System to Serve: 9-House ,�-❑ Mobile Home ❑ Place of Public Assembly ❑ Business ❑ Industry ❑ Other ❑ Unknown 5. If house, mobile home: Subdivision ✓'"' Section Lot # ❑ Basement/Plumbing No. of People 3 ❑ Basement/No Plumbing No. of Bedrooms 3 Ef Washing Machine No. of Bathrooms a YZ B Dishwasher Dwelling Dimensions I S o© '59. 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 u,"L c:JA ❑ Private ❑ Community 8. Property Dimensions acles 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: p r L 0 A let kc,Aj iCQe of '$ OFQjiC� (� l S.-c 5 --rc,:(e-� PC--J- p vcX ocfo55 S0,� This is to certify that the information provided is correct to the best of my knowledge, and 1 understand I am responsible for all charges incurred from this application. - // - 9y w,� DATE SIGNATURE CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY Ftaondcodisposal ECK ONE: ❑ 1. 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 representative of the Davie County Health Department to enter upon above described cated in Davie County and owned by all testing procedures as necessary to determine said site's suitability for a ground absorption sewage treatment system. DATE SIGNATURE DCHD(1193) I APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT Davie County Health Department RC fepVE® Environmental Health Section tG P. O. Box 665 JA N — 3 Mocksville, NC 27028 --------------- 1. Application/Permit Requested By- -111)-rAt 1A,1 04 ibwif)b Mailing Address r.LW l� G 0 Home Phone���� 1�3�'3 q� Business Phone Qa$ 121 or X5- 52-V 2. Name on Permit if Different than Above 3. Application/Permit for: ❑ General Evaluation Septic Tank Installation 4. System to Serve: Gd House ❑ Mobile Home ❑ Place of Public Assembly ❑ Business ❑ Industry ❑ Other ❑ Unknown 5. If house, mobile home: Subdivision SectionLot# &r/Basement/Plumbing No. of People — Basement/No Plumbing No. of Bedrooms 3 C�'/Washing Machine No. of Bathrooms U/Dishwasher Dwelling Dimensions 2 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: IQ/Public ❑ Private ❑ Community 8. Property Dimensions 16.7 rig C%-C-r e-S Sewage Disposal Contractor / 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes W 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: ko� 0n Gaxoss - rop, Q1nes Trailer �ar(� /�� � c-nc� be sic e� �i� 00A- R"j �a rr �-T I- �4 lk � IL/V-- Cl- This is to certify that the information provided is co ect to the best of knowledge, and I understand I am responsible for all charges incurr d from this application. Z o , tA. J44--' DATE SIGNATURE 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 f r MUST be completed by the owner o,a person authorized by the owner: I hereby give consent to the authorized representa veAf the Davie County H II artment to enter upon above described property located in Davie County and owned by,g r,a to conduct all testing procedures as necessary to determine said site'd suitability for a ground absorption sewage treatment and disposal system. /�✓ 3 / - 23 0 03, ti DATE G01SIATURE DCHD(12.90) C _ � DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation ) NAME ) DATE EVALUATED F ' C� Ll ADDRESS s P �`^s' PROPERTY SIZE PROPOSED FACIILTY LOCATION OF SITE Water Supply: On-Site Well Community ?' Public Evaluation By:C"Z_L Auger Boring V Pit Cut FACTORS 1 2 3', 4 Landscape position S _S •-s -Z Sloe 9. •�° -Ssb O - - HORIZON I DEPTH �` • 6�' Texture group L Consistence r - Structure R C. Mineralogy1' � 1: ►1 HORIZON II DEPTH " 21' Z" _-° Texture groupC C Consistence Structure Wa4"- Mineralogy HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS .� G -SS ..S.s RESTRICTIVE HORIZON .. SAPROLITE ^-- CLASSIFICATION S S LONG-TERM ACCEPTANCE RATE 1 .4 SITE CLASSIFICATION: Q'S EVALUATED BY: ( �. LONG-TERM ACCEPTANCE RATE: kU _ g OTHER(S) PRESENT: z- REMARKS: VA q 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 ��.iiiiiiii��