203 Mr Henry Rd y �•••.Y•-4:-rF.";tF ,.:.�Wi} ? ...._ t u „•.,_✓ 7..:,.. � Y`ii!";.,. ,i=_�,,:... i^.� ._ e' '�. a .`m{ . .,. .. `:,� , , _ 'i .. Y_
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DAVIE COUNTY HEALTH DEPARTMENT OXO
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTE:Issued in Compliance With Article II of G.S.Chapter 130a
nitary Se agg Syste�r�s Permit u r
Name /Date NO 7—
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 ❑ � �
Sp c' i o s.,for S stem: rr
Auto Dish Washer YES NO ❑ `�
Auto Wash Ma shine YES O ❑ � `�" �/
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.
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
/y0
/Q n
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 PERMI C Davie County Health Department RECEIVED
Environmental Health Section
P. O. Box 665 SEP 15 1992
Mocksville, NC 27028
------
1. Application/Permit Requested By AZ4 h Glvlw�
Mailing Address 20. 6otC /0? aC�(s►/i'���
s
Home Phone Gly• 5/6 Business Phone 279 "b515
2. Name on Permit if Different than Above
3. Application/Permit for: ❑ General Evaluation G.Septic Tank Installation
4. System to Serve: R House ❑ Mobile Home ❑ Place of Public Assembly
❑ Business ❑ Industry ❑ Other ❑ Unknown
5. If house, mobile home: Subdivision Section Lot#
N Basement/Plumbing
No.of People 'T ❑ Basement/No Plumbing
No. of Bedrooms 3 Washing Machine
No. of Bathrooms �2 Dishwasher
Dwelling Dimensions HOn2a y, ����D EJ Garbage Disposal
ry
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: ❑ Public 9 Private ❑ Community
8. Property Dimensions 49 kl?ts Sewage Disposal Contractor
9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes B-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:
. Ig'- go,w o
56
This 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.
/S-'02
DATE SIGNATU E
CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY
MUST CHECK ONE: ❑ 1. 1 OWN the property. K2. 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 of the Days"e Cou ty Fjea-lth Pep4riment ent r o, bovv esc�ri�bed
property located in Davie County and owned by � l
to conduct all testing procedures as necessary to determine said site' suitability for gr nd absorption sewage treatment
and disposal system.
DATE
SIGNf URE
DCHD(12.90)
r
� . r
'' "�► DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
\ Soil/Site Evaluation
NAME 1��� A h DATE EVALUATED
ADDRESS s A Ccv.Q PROPERTY SIZE \` �
PROPOSED FACIILTY v s 4 LOCATION OF SITE �V ��A
Water Supply: On-Site Well Community Public
Evaluation By:ttl- Auger Boring 1/ Pit Cut
FACTORS 1 2 3 4
Landscape position
Slope 7. - `L �s6 •$ ( -8° O
HORIZON I DEPTH 6 6
Texture group C. C C_ C,
Consistence V 1=T V F-. VF7- Vim- F1'
Structure Z
Mineralogy ', I ) ; 1 ►. I 1 . 1 :1
HORIZON II DEPTH it d 113 0 U tA
Texture group ZIC C I C C
Consistence V\%"\'K I/F-Z V F-1 r V FZ.
Structure
Mineralogy2
HORIZON III DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS V
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION V .S V S
LONG-TERM%ACCEPTANCE RATE /y
SITE CLASSIFICATION: "!�"� pd �ALUATED BY:
LANG-TERM ACCEPTANCE RATE: OTHER(S) PRESENT:
REMARKS:
.LI,GGENDD�..�r, —�—
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 neraloizy
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