942 Angell Rd (3) DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTE:Issued in Compliance With Article 11 of G.S.Chapter 130a
Sanitary Sewage Systems �� �� Per it Number
Name 1 , c� � f� !x:4_7/ Date 1S_/PA/) N_ 5963
- �'7l�'
Location <1.1JW—
k' f'�f✓ lf��a ✓ ar,r i% r7/J�r „�
Subdivision Name Lot No. Sec. or Block No.
Lot Size ,��f��% House — ''� Mobile Home _ Business Speculation
No. Bedrooms — No. Baths =-'T7 No. in Family _
Garbage Disposal YES ❑ NO ❑ Specifications for System: _ ,U,
Auto'Dish Washer YES ❑ NO ❑ !� /
Auto Wash Machine YES ❑ NO ❑ �d r�,�AP
Type Water Supply CJI'
*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 Z !�Zl
*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 b ,� �31__�!/ren w�
Iib
F,
r
Certificate of Completion 4Z 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 taken as a guarantee that the system will function
satisfactorily for any given period of time.
i
APPLI9ATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department
1 r Environmental Health Section r'V
f� n P. 0. Box 665 RECF
D A� Mockaville, NC 27028 EQ APR i 9
1 . A lication/Permit Requested By To/Yl n e ca llo A
Mailing Address S+ra7 To►-c( Ad. U),-4,1-Im- Sa(2n./11 Com, x7100
Home Phone "� fc5-S�S/Q`4 Business Phone
2. Name on Permit if Different than Above
3. Property Owner if Different than Above
4, Application/Permit For: general Evaluation & S/Tank Installation
5. System to Serve: 2--Rouse u Mobile Home 0 Business
L Industry u Other 0 Unknown
6. If house, mobile home: Subdivision Sec. Lott
No. of People 1Z Dwelling Dimensions
No. of Bedrooms J � Basement/Plumbing
No. of Bathrooms 3Easement/No Plumbing
Gashing Machine dishwasher 0-Ir-arbage Disposal
7. If business, industry, 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
S. Type of water supply: C Public g4rivate Q Community
9. Property Dimensions _�GV�CcQ
. 10. Sewage Disposal Contractor
11 . Do you anticipate additions/expansions of the facility this system 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.
This is to certify that the information provie dis correct to tree
best of my knowledge, and I un I am rEI nsible for all
charges incurred from thi pplicat.ion.
4-N-90
Date Signature
Directions to Property : '-J'J e O
/3 LA3�
(,�oodeclave� �oael� �, roj
,,Ya ,fid R.de.-
Y
Talo W Qodward -� Q1'1g4e-t P-oaC(
Of) e II n� ro Y rtc�� ite
�►/�Pe/r i s rr�nf, "_VP ��/ 'o
cod
C' 5 (,,C-(c b( v n- ar'"L;l�3
CC&(/ -CI c�a D�� , a a�
_��
n,& d yon
DCHD (10-89)
Davie County Health Department
Environmental Health Section
T..` Site Evaluation Consent Form
LOCATION OF PROPERTY: DATE RECEIVEDi"'
(office use only)
n �/ Rd. Rf. !, l�'co Ck.5V1 Ili
yes no 1. 1 am the owner of the above described property.
yes no 2. 1 am not the owner of the above described property, however, ( certify that I
have consent from , owner to obtain a
owner's name i
site evaluation by the Davie County Health Department for the purpose
:, J.
determining the suitability for a ground absorption sewage treatment
disposal system.
es no 3. 1 hereby give consent to the authorized representative of the Davie County
Health Department to enter upon the above described property and conduct all
testing procedures as necessary tM-" S)dNATURE bility for a ground
absorption sewage treatment and
-/V-90
DATE
4. 1 hereby authorize the Davie County Health Department to release site
evaluation results from the above described property to the following:
✓Owner only
Owners designated representative
—Anyone requesting results
Only those listed below
DATE SIGNATURE
DCHD(11/84)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
NAME , e4' l� DATE EVALUATED
ADDRESS PROPERTY SIZE l�
PROPOSED FACIILTY LOCATION OF SITE , iV/�`J AV
Water Supply: On-Site Well Community Public
Evaluation By: Auger Boring Pit Cut
FACTORS 1 2 3 4
Landscape position
Slope 7.
HORIZON I DEPTH a r-
Texture group 'A
Consistence
Structure aleSb�
MineralogX , i
HORIZON II DEPTH
Texture groups.
Consistence
Structure ( r S'h Ile
Mineralogy
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 RATE
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 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
■■■■■■■■■■.■■■■■■■■■.■■■■.■■■■■■■.■■■■■■..■.■.■■■■■■■■■■■■■■■OMEN■
■■■■MMM■■■■■.■■■■■■■.■■■■■■■■.■■■■ ■■■■■■■■■■■■■■■■.■.■■■■■■■■■■.�
■.■....u..■.■m....w.......■■■■. ■■■..■■+■■■■■.■..■■■■■■.■■■■.�i■■m
■■■■■.■■.■■■■■.■■■■■■.■■■��■■■.■■■■■■■....■�■■■■■■.■■.■■■■ ■OMEN■■■
■■■■■■ ■m■■■■ ■■■■■■ ■■■■■■ ' ■■■■■■ loom■■■ ■E■E■■ ■ENNEN
■■■■■■■■■■■■■■■■■■■■■...■ISO■■■■■.■.■■■■■■■It■■■■■.■.■■■■■■■■■■■■■■■
■....■■■.■■■.■■■■■.■..■■■1/■■■■■■iii■■H.■■Mm■■.■■■■■mE■■■■■■■ MEMO
iiiii=iiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiMiiiM�iiiii iiiiiii■�iii■iiiii=
MNMMMMMMXMMMMMMMMMii�iiiiiiiiiiiiiii=iiiiiiiiiiiiiiiiiiii�■iEiEiiii
NOMMEME MEN�i ■�iiiiiiiiiiiiiiiiiiiiiiiiiiii■i�iii.�ON
................................ ................................
............................................■.....................
..................................................................
■■■.■.■NOON■■■■m■■■■■.■■■.■.■m.■■■.....m■■■■■■..■■■m■mO■�.■■.■m■■
■■NEEM■■E■■NN.M■■■■._..........■ ■■....■.■■.■■■■■■■■■■■■■■m.■.■.■