447 Baileys Chapel Rd _ .. T. n .�..1 r"1 1 .. a i 4.^1•, a t4�i• - N • . .. .. r, . rr��� 't-.
! DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTEAssued in Compliance With Article I I of G.S.Chapter 130a _
Sahitary Sewage Systems,, �,:,:v f�►yrr Permit Number
Name to 12/ N
`
Location ,� "� , l; ,� ;�° ._ � � 7-
Subdivision Name Lot No. - Sec. or Block No.
Lot Size -1% ' House Mobile Home _T Business Speculation
No. Bedrooms /// .No. Baths _T_ No. in Family. yf�"
Garbage Disposal YES ❑ NO Specifications for System:
Auto Dish Washer. YES ❑ NO
Auto Wash Ma shine YES ❑ NO
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.
F t,r7�vd)
lU
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: , a,Q System Installed bye?
Certificate of Completionl � 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.
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
NAME DATE EVALUATED
ADDRESS PROPERTY SIZE lb9
PROPOSED FACIILTY LOCATION OF SITE
Water Supply: On-Site Well Community Public_
Evaluation By: Auger Boring Pit Cut e/—T
FACTORS 1 2 3 4
Landscape position L L L
Sloe Z 41 3iy
HORIZON I DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH 2 yd Yv
Texture group C
Consistence
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 S— s
LONG-TERM ACCEPTANCE RATE //
SITE CLASSIFICATION: !!• EVALUATED BY: Z�2 -&
LANG-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 - to 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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. APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section 12ze.
' P. 0. Box 665
Mockaville, NC 27028
1 . Application/Permit Requested Bytir9��,o � _
Mailing Address f' 4 /3 11,
Home Phone ,�I G -,21?Z4 �j �� Business Phone �D =y 3 �l•fig_
2. Name on Permit if Different than Above Lm, ,V �-S ��uS9r��1.� ,,A�
3. Property Owner if Different than Above &4C� i— )e 9r' dc�
4. Application/Permit For : 0 General Evaluation &4-/Tank Installation
5. System to Serve: House Mobile Home $-�Usiness
0 Industry Other 0 Unknown
6. If house, mobile home: Subdivision Sec. Lot#
No. of People Dwelling Dimensions
No. of Bedrooms Basement/Plumbing
No. of Bathrooms Basement/No Plumbing
0 Washing Machine Dishwasher 0 Garbage Disposai
_ _-A � .. .
7. If business, industkry, 'oth6r: Specify type 4-4l+C )1 ; ,n S•��D
No. of People Served �� No. of Sinks
No. of CommodesNo. of Urinals .�
No. of Lavatories 1 No. of Water Coolers
No. of Showers
S. Type of water supply: Public 0 Private 0 Community
9. Property Dimensions
10. Sewage Disposal Contractor let+11 � ,
11 . Do you anticipate additions/expansions of the facility this system is
intended to serve? 0 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 provided is correct to the
best of my knowledge, and I understand I am respo for all
charges incurred from this application.
44:—gC1 —cy!l
Date Si
Directions to Property :
NA
DCHD (10-89)