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114 Harness Ln (2) �,. C'P".. �•,.N_..� r: _ r ��i _ -. } ,t. DAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION *NOTE:Issued in Compliance With Article 11 of G.S.Chapter 130a Sanitary Sewage Syst ms, � Perml er Name l D, Ti�J'� all T ,gip. Date _/ ,T p Location Subdivision Name Lot No. Sec. or Block No. Lot Size House Mobile Home Business Speculation - No. Bedrooms ��.No. Baths �—No. in Family Garbage Disposal YES ❑ NO 0 Sp clifications,4or System: `Auto Dish Washer YES 'i NO E] ��''� Auto Wash Ma shine YES NO NO ❑ IJ �,� � 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. Ci r; 1 1 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: System Installed by AV tob t'. 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. APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT Davie County Health Department Environmental Health Section P. O. Box 665 ��•� Mocksville, NC 27028 1. Application/Permit Requested By. ,J wlt ,g z>5 Mailing Address t��. S' Lao �c 3 73 12Ia c,<5y;ZZ ' AfC Home Phone �f �' �`�� Business Phone X8414 2. Name on Permit if Different than Above 3. Application/Permit for: ❑ General Evaluation Septic Tank Installation 4. System to Serve: ❑ House E?Mobile Home ❑ Place of Public Assembly ❑ Business ❑ Industry ❑ Other ❑ Unknown 5. If house, mobile home: Subdivision Section Lot # ❑ Basement/Plumbing No. of People ❑ Basement/No Plumbing No. of Bedrooms ®'Washing Machine No. of Bathrooms ❑ Dishwasher Dwelling Dimensions q- x r'od ❑ Garbage Disposal 6. If business, industry, place of public assembly, 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 Water Usage Figures 7. Type of water supply: Q'Public ❑ Private ❑ Community 8. Property Dimensions Sewage Disposal Contractor 'tS 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes O 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. Directions to Property: - vy- 'lid g,,_ /fG b 7otJ llL — ,rfo-T- )',577- This am TThis is to certify that the information provided is correct to the best of my knowledge,and I understand I am responsible for all charges incurred from this application. -2-45 3 DATE SIGNATURE CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY MUST CHECK ONE: 9' 1. 1 OWN the property. ❑ 2. 1 DO NOT OWN the property. If you checked Box #2, the rest of this form MUST be completed by the owner or a person authorized by the owner: I hereby give consent to the authorized representative¢1 the Davie County Healt Department to enter upon above described property located in Davie County and owned by ( �,() to conduct all testing procedures as necessary to determine sad site's suitability for a ground absorption sewage treatment and disposal system. a DATE SIGNATURE DCHD(12.90) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation J NAME e�- DATE EVALUATED ADDRESS PROPERTY SIZE 4 i� " PROPOSED FACIILTY LOCATION OF SITE 20/�dl0 Water Supply: On-Site Well Community Public Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3 4 Landscape position Slope % HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH Texture groupC 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 LONG-TERM ACCEPTANCE RATE / SITE CLASSIFICATION: EVALUATED BY: -77i�. 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-F^fable FI-Firm VFI-Very firm EFI-Extremely firm -ly sticky S-Sticky VS-Very Sticky `ly plastic P-Plastic VP-Very plastic CR-Crumb GR,-Granular ABK-Angular blocky ?laty PR-Prismatic es from land surface $ to free water' or inches from land surface to soil colors orally suitable), U(unsuitable) al/day/R2 ■//■.■/■/■/.//../..■■/.//.■■■■///.■SSSS■./.■..■..■...■...■......�■ ■■■■■■■■/■■■■■■■/■■■■■■■■■■■■■//�■■■//■MOOS■■/■■/■/■■■■■■■■■./■.■ ■.■..//■.■..■■.■//.//■///../..■....SSSS■SSSMS.■■■.S■......M.■M..i■ ■..■.■.■.......■■....■..........■...o..Ou.■.uu■.0■.u..uNMEMO■■!.u■ No ...■.............■...■..■...■.■. .■......■......■....■■■.Moi..■.■ ■.....■■■■....■■■■■.■■■u..u.■..N■■ ■....■■■.■■■■■■■■■■■■■■■■■■.■■■ ■.....■...■......■....■.■../■/.■............■■..■■■..■..■...■.�■.. ■/.../■■...■.../..■.■.././/■.■■■///./■■/■/SSSS.//■SSSS/.■./..//■ ■ f.■...M■■.M..■.■.M..■M..■SM■MSS■..■M..■SSSS■.■..■...■P/■....■■....■ ................................................../SSSS.. 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