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1153 Main Church Rd DAVIE COUNTY HEALTH DEPARTMENT J U , G1V - IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION *NOTE:ISSUed in Compliance With Article I I of G.S.Chapter 130a Sacitary,Sewage Systems Permit Number Name � � -�,;��c. Date �� - ! :� Np 6203 Location t Subdivision Name � of No. Sec. or Block No. Lot Size House Mobile Home _ Business Speculation No. Bedrooms No. Baths No. in Family Garbage Disposal YES p NO g Specifications for System: Auto Dish Washer YES NO ❑ f ��c,c.,, �' - C� a V Auto Wash Machine YES p,, 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. r� '-2 Improvements permit by \_ =r *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 byiT ins'! t �6 ll'al Ce ificate of Completion Da__te "The signing of this certificate shall indicate that the systerg described bove has been 'nstalletl-in-compliance with the standards set forth in the above regulation, but shall in NO.yvay be taken as a guarantee hat-thesystem will function satisfactorily for any given period of time. '`� r APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT Davie County Health Department �y®� 5 um Environmental Health Section �� R 0. Box 665 / I Mocksville, N.C. 27028 CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED. Home Phone 1: Permit Re sted By I Sm Business Phone 2. Address �: o , e 7oZ -3. Property.Owner if Different than Above Address 4. Permit To: a). InstalL,L Alter— Repair b) Privy Iz Conventional Other Type Ground Absorption c) Sub-Division. ` ° Sec. Lot,No. 5. System used to serve what type facility: House t,,' Mobile Home Business Industry Other b) Number of people _ 6. a7 If house or mobile home, state size of home and number of rooms. House Dimensiops IQ Bed Rooms . Bath'Rooms _3 Den w/Closet l 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 3 urinals garbage disposal lavatory showers 3 washing machine dishwasher / sinks_. 8. a) Type water supply: Public Private_Community b) Has the water supply system been approved? Yes_15t!:�No 9. a) Property Dimensions 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? /VD What type? at This is to certify that the information is correct to the best of my knowledge. Date Owner Signature OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL,LAWS Allow 5 days for processing Directions to property: r ' r I q*e- n y L r t 1 IL-4- : r elm Re LA-1-12 S 5`Z>�� r *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. DCHD(6-82) f t DAVIE COUNTY HEALTH DEPARTMENT ENVIRONMENTAL HEALTH SECTION SITE EVALUATION CONSENT FORM 1. Complete the form below and return to the Davie County Health Department. 2. Carefully follow the procedures as outlined in the enclosed "Information Bulletin." NOTE: THE ABOVE MUST BE COMPLETED BEFORE A SANITARIAN WILL BE ABLE TO BEGIN THE REQUESTED EVALUATION. DETACH HERE AND RETURN TO: Davie County Health Department, Environmental Health Section, P. O. Box 665, Mocksville, N.C. 27028 Davie County Health Department Environmental Health Section Site Evaluation Consent Form LOCATION OF PROPERTY: DATE RECEIVED ej (office use only) Les 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, I certify that I have consent from , owner to obtain a owner's name site evaluation by the Davie County Health Department for the purpose of determining the suitability for a ground absorption sewage treatment and disposal system. yes no 3. 1 hereby give consent to the authorized representative of the Davie County Health Departmentto enter upon the above described propertyand conduct all testing procedures as necessary to determine its suitability for a ground absorption sewage treatment and disposal system. D TE SIGNATURE 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 AT SIGNATURE DCHD(11/84) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation NAME � _ � DATE EVALUATED 9 V ADDRESS S -"`��` PROPERTY SIZE 1J C�s�Sy� PROPOSED FACIILTYLOCATION OF SITE Water Supply: On-Site Well Community Public Evaluation ByC kL.,Auger Boring I/ Pit Cut FACTORSW 2 3 4 Landscape position S -S Slope % cti g- o HORIZON I DEPTH D " I r' a q%3 Texture group L- � C CL_ Consistence 11 TM - Structure Mineralogy l" HORIZON II DEPTH cd Texture groupC. Consistence Structure S'B't_ S I V_ Mineralogy 11 I1 ZI HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS S S V S V-5 RESTRICTIVE HORIZON SAPROLITE n -�- CLASSIFICATION S S s LONG-TERM ACCEPTANCE RATE .._ SITE CLASSIFICATION: Q S EVALUATED BY: � C'►Jam' LONG-TERM ACCEPTANCE RATE: � w OTHER(S) PRESENT: REMARKS: ZN » 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 Mi neralmy 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 ■../■/■ee■e■e■/e..e■e.e■.eeee■.■ ■■./■■■e■.■■.■e■/eee■■.eee■■ee■■ ■■...s../■e■e■ee■■e■e■e■■ee■■■■e�i/■■■/ee.ee■■■■■.■■/e.■.e■e■e/■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■.e■■ee■■■■■■■elu.■.■.■■e■ee.■e�.■....ee/e■/e■■■■./■ee.e.■..ee.■ ■■e./ee.e■■■..e.e.■■ee■e.e.■■e■■ ■■■e■ee.e■■1�/e/e.■.■/e■■e■■e../■ ■■....■..■..■■■el..e■■ee■.e.e..e■.e.e/./.e.e■ ■ee■■...e....e...■.■ ■..e.■■■■e/■e.■■...■...eee..Ne.■■/■.../■■...■......■■.e.H■.e■..■ ■■ee.e.■■...ee..■..■..■e.■■■ee■.■■e.■.e..eeee■.■..e.■■e..eeeee■■e■ ■..e■e.■■■/e.eee■t.■■e...■■/■■■■■e.■■/■■.ee■■■■..■■/e■.e.■/■■.e..■ ■..■■.ee.■eee■.e■.■e■■.■.■..e.■....■ecce■.e■e..■■..e■...■■..■■...■ ■e■■/■ee■■■.....e..ee■.e=■.eee■. ■■■■■■■■./eee....ee■■..■.■e.■■■■ ■iiiiiiiiiiiiiiiiiiii�iiiiiiiiiiiiiiiiiiii■�iiiiiiiiiiiiiiiiiiiiii ■■■!.■■!.!!■■!■.■..■e.■.!■■■■■■■.■!.■!..!■..e.■■■....1�■.. 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