1903 Angell Rd (2) GO 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 Permit Number
Name Date �5 -y�111,� N2 . 5984
Location
Y,
Subdivision Name Lot No. Sec. or Block No.
Lot Size . AltHouse Mobile Home /L' Business Speculation
No. Bedrooms _ No. Baths No. in Family_,e
Garbage Disposal YES ❑ NO Specifications for System:
Auto Dish Washer YES ® NO ❑
Auto Wash Machine YES a NO ❑ � �� �' ,�
Type Water Supply lxzllf`r
*This permit Void if sewage system described below is not installed within 5 years fromda�issue LJ
This permit is subject to revocation if site plans or the intended dib change.
pt
Improvements permit by ( L
*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
�/Z''
-Fb I `'
f
Certificate of Completion ^^ ° Date
stem describ'�d above has been installed in com liance with
The signing of this certificate shall indicate that the system p
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 J
PROPOSED FACIILTY ZZ A/" LOCATION OF SITE //,l A:P
Water Supply: On-Site Well Community Public
Evaluation By: Auger Boring Pit Cut
FACTORS 1 2 3 4
Landscape position . ,Q
Sloe % _� 2
HORIZON I DEPTH <
Texture group -r4-
Consistence
Structure a-
MineralogX
HORIZON II DEPTH �i -f y -y
Texture group
Consistence
Structure Irlb ( ,r
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: 7' EVALUATED BY:
LDNG-TERM ACCEPTANCE RATE: G/ 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
........................... ......................................
■■.■...N...■■e.l�7.■w..■!�■..■■■. .■■.■..C�■...■■■....■....■...�■■■
■........■.■■■..Gni.■■■■tcii■.....�■......[I►7■■■■..■.■■■■■■■.■■■■■■■
■■■■■■..■i■■■■■■■ill■■■■■L��t■■....1�■......./■.■■■■..........■...■ ■
...... ...... ...... ...... ...... ...... ...... ...... .
...... ■■■w.■ ■■■■■■1�■■■■.■ .■■■■■ ■■■■■■� ■■■■■■ ■■■■■■�
■■■■...■■.■.■■■■■■■■■■■■■■■■■■■■iii■■■.■■■■■■■■■■■■■■■e...... ...■
:::::CCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCC::C�CCCCC'CCC:CCCCCCCCCCC
CCC::=::::::::CCCCCCCCCCCCCCCCCCCCCCCCCCCCCCC�:_�CCCCCCCCCCC�:_
CCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCC�:CCCCCCCCCCCC:CCCCCCCCCCCCCCCCCC
CCCCCCC"CCC'CCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCC'CC
CCCCCCC:=MEN ECCCCCCCCC'CCCCCCCCCCCCCCCCCCCC'CCCCCCCCCCCCCCCCCCC:CC
■■...w...■.■■■w■■■■■ ■...■■..... ■..■.............■........■..■.■
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section
P. 0. Box 665 66
Mockoville, NC 27028
1 . Application/Permit Requested By ���% / �,(��r '04—
Mailing Address V'W—,o
Home Phone �(����y�"' $�� Business Phone
2. Name on Permit if Different than Above
3. Property Owner if Different than Above
4. Application/Permit For: General Evaluation �/Tank Installation
5. System to Serve: House a-lobile Home 0 Business
0 Industry u Other 0 Unknown
6. If house, mobile home: Subdivision Sec. Lotit
No. of People Dwelling Dimensions
No. of Bedrooms _ Basement/Plumbing
No. of Bathrooms j Basement/No Plumbing
®' Washing Machine 2, Dishwasher 0 Garbage Disposal
7e 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
8. Type of water supply: C Public 2000private 0 Community
9. Property Dimensions , }c , -&'f e,
10. Sewage Disposal Contractor
11 . Do you anticipate additions/expansions of the facility this system is
intended to serve? 0 Yes 0 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 informatior► provided is correct to tri C!
best of my knowledge, and I understand I am responsible for all
charges incurred from this application.
-9 & - �e
Date Signature
Directions to Property :
dol ov-
h7 fob
111064re -7;�-ke Ile
DCHD (10-89)