P6420 Major Rd 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 J C / Permit Number
Name t/.�?>,�?/f�.�c/�F%I<�/ /��.T Vii'/ , i..r_ • �[fa{e " - �1 N2
Location
,�.,5 �:_ l!"! l.;ri//,. .>��f'r°/' �/ `,� 4'-,/ "�//'r•':r' �, ,.1, ..� ,; ~'y' �_^,.� �,r�iiJ �''/'-__����/
Subdivision Names Lot No. / Sec. or Block o.
Lot Size House Mobile Home _l--T Business Speculation
f
No. Bedrooms - No. Baths No. in Family 2 _
Garbage Disposal YES ❑ NO Er Specifications for System:
Auto Dish Washer. YES T NO ❑ / ` / �, .&/V
Auto Wash Ma.hine YES NO ❑ r� '
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
1
Improvements rovements Permit b --
f
!
*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 by
EvEr)
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K
it J
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 taken as a guarantee that the system will function
satisfactorily for any given period of time.
'4
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PER EP IVE
Davie County Health Department M'
Environmental Health Section JUN 03
P. 0. Box 665 1991
Mocksville, NC 27028
1 . Application/Permit Requested By ► ►�X�IC �� ( cam' �N
Mailing A d d so ) 7!P ay', l T U ?y C- a0 1 1
Home Phot -7�11.1 'rQ /!4l Business. Phone
2. Name on Permit if Different than Above
3. Property Owner if Different than Above
4. Application/Permit For : General Evaluation a-S/Tank Installation
5. System to Serve: 0 House eMobile Home 0 Business
Industry u Other 0 Unknown
6. If house, mobile home: Subdivision Sec. Lot#
No. of People Dwelling Dimensions
No. of Bedrooms `3. Basement/Plumbing
Na. of Bathrooms 1 �s.�. Basement/No Plumbing
(Washing Machine ;Dishwasher 0 Garbage Disposai
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: E,,---'P-ublic C] Private Q Community
9. Property Dimensions
10. Sewage Disposal Contractor
11 . Do you anticipate additions/expansions of the facility this system is
intended to serve? 0 Yes T—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 thF,
best of my knowledge, and I understand I am responsible for all
charges incurred from this application.
Date Signature
Directions to Property :
/5�•� � �`�`'- c n ���'�mc'���,19. > ,L�-. oma--�e0-etc/�aY,-. ( , .
off- `�'>'1a�o -`-(1�• J ��� 6
1�•�' � (�1.�r 1� � '� ��-�2.�� • ��- P� �``J�'�'-rte- � �," �ia.c•
DCHD (10-89)
•� •` ' DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
NAMEzalaa )o DATE EVALUATED d'�I
ADDRESS PROPERTY SIZE
PROPOSED FACIILTY LOCATION OF SITE
Water Supply: On-Site Well Community Public-/---,,"
Evaluation By: Auger Boring Pit Cut
FACTORS 1 1 2 3 4
Landscape position L L L.
Sloe %
HORIZON I DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH
Texture groupL�
Consistence r
Structure
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 RATEI .
SITE CLASSIFICATION: EVALUATED BY: f1�
LONG-TERM ACCEPTANCE RATE: t 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
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