P6345 McCullough Rd » f-"_:. 1 'Si:"vJ r l}"'r a"e=p:Y1 4 ; t d 4(: ` 3Y:• ,1 ^i < � r 'o` '-t�i e'Y
DAVIE COUNTY HEALTH DEPARTMENT 1 �
IMPROVEMENTS PERMIT AND .CERTIFICATE OF COMPLETION 3 b 71W
*NOTE:Issued in Compliance With Article II of G.S.Chapter 130a
Sanifary Sewage Syste sk✓ Permit Number
Name
Date No 5.
Location
Subdivision Name Lot No. Sec. or Block No.
Lot Size %�F House Mobile Home _�-''r Business Speculation
No. Bedrooms - —.No. Baths — — No. in Family _
Garbage Disposal YES ❑ NO p''r Specifications for System:
Auto Dish Washer YES NO ❑ ���
Auto Wash Ma^hine YES NO ❑
Type Water Supply
*This permit Void if sewage system described below is not installed within 5 years from date of issue.
Thispermit is subject to revocation if site plans or the intended use change.
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 � ����-- ---
_ t
IQQ
s � J
Certificate of Completion ` Date V '
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.
•> Q�APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section
P. 0. Box 665
V Mockoville, NC 27028 �(', � An
:-\ALpliccation/Permit Requested By
ng Address
Home Phone I0 - /�'/•'ao�0 Business Phone
2. Name on Permit if Different than Above
3. Property Owner if Different than Above
4. Application/Permit For: 0 General Evaluation Q/S/Tank Installation
S. System to Server House /Mobile Home 0 Business
L Industry u Other 0 Unknown
6. If house, mobile home: Subdivision Sec. Lot#
No. of People o2' Dwelling Dimensions
No. of Bedrooms Basement/Plumbing
No. of Bathrooms ,- 7 Basement/No Plumbing
(/Washing Machine J Dishwasher 0 Garbage Dispusai
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
8. Type of water supply: C Public (Private p Community
9. Property Dimensions I a-
10.
10. Sewage Disposal Contractor
11 . Do you anticipate additions/expansions of the facility this system is
intended to serve? 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 responsibl for 11
charges incurred from this appl c tion.
Date VV Signature
Directions to Property :
04-15 • " �, ax ; �C' Ila `�� , moi. ak t-.Ft -� /a/-i
)44n
DCHD (10-89)
f DAVIE COUNTY HEALTH DEPARTMENT
-� Environmental Health Section
Soil/Site Evaluation
NAME DATE EVALUATED
ADDRESS JJ PROPERTY SIZE
PROPOSED FACIILTY �- /���'� LOCATION OF SITE `L .t
Water Supply: On-Site Well Community Public
Evaluation By: Auger Boring Pit Cut
FACTORS 1 2 3 4
Landscape positionSlope % 3 2 2
HORIZON I DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH -Y
Texture group
Consistence r
Structure .f57;4lf'
Mineralogy1
HORIZON III DEPTH
Texture grou2
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE
SITE CLASSIFICATION: �S' EVALUATED BY:
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-Coticave 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 watet'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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