212 Norma Ln I, Xa
CI - DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
•NOTE:Issued in Compliance With Article 11 of G.S.Chapter 130a
Sanitary Sewage S s temA Permit Number
Name l� S- f 1 �� Date 1 // NO 7108
Y
Location
____.��1JL/l�c�' L� � � �,��/ - �Y t_��z�� l;' j�it C� /r o �!'�'1 fl G..-l1/•
Subdivision Name �• Lot No. Sec. or Block No.
Lot Size �G House l� Mobile Home _T Business _— Speculation
No. Bedrooms No. Baths No. in Family_�—
Garbage Disposal YES ❑ NO FT" Specifications for System:
Auto Dish Washer YES [:],,NO
Auto Wash Ma.hine YES El NO ❑ /D�fD�` "✓f' y�`
Type WaterSupply
—
*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.
V \ -
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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. t
Final Installation Diagram: System Installed by �u2
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V e r/G t'
bpd ioa
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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 �T@ l2 D WE
Davie County Health Department 5 V l5
Environmental Health Section I�
P. O. Box 665 O
Mocksville, NC 27028
1. Application/PermiittRRe-q�u�ested By_Pq uS ° IJ ,�I 15
Mailing Address KT � 13o� --1,-7 19 �y 02 Iv L e- J L° , A200 ,4
Home Phone 75 = u��1S Business Phone S M Q—)
2. Name on Permit if Different than Above
3. Application/Permit for: ❑ General Evaluation IrSeptic Tank Installation
4. System to Serve: MIAouse ❑ Mobile Home ❑ Place of Public Assembly
❑ Business ❑ Industry ❑ Other ,,� El Unknown
5. If house, mobile home: Subdivision d 1,/ ,DSVF�dPM�Section Lot #
❑ Basement/Plumbing
No. of People �� �Bp ❑ Basement/No Plumbing
No. of Bedrooms 3 93"Washing Machine
No. of Bathrooms ❑ Dishwasher
Dwelling Dimensions ❑ 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: V Public ❑ Private ❑ Community
�/�j� i
8. Property Dimensions '� Gt-C. --�.�n Sewage Disposal Contractor c�•o�_
9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes 0
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
a to�Progpe� iOfF o o J R-1—e- o d of �f d Y m-a "
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.
— a
DATE SIGNATURE
CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY
Fanddisposal
ECK ONE: Rl. I OWN the property. ❑ 2. 1 DO NOT OWN the property.
ked Box #2, the rest of this form MUST be completed by the owner or a person authorized by the owner:
ve consent to the authorized representative of the Davie County Health Department to enter upon above described
cated in Davie County and owned by
all testing procedures as necessary to determine said site's suitability for a ground absorption sewage treatment
system.
2 4 3 ^—
DATE SIGNATURE
DCHD(12-90)
DAVIE COUNTY HEALTH DEPARTMENT
' Environmental Health Section
Soil/Site Evaluation
NAME .�-� /`� S DATE EVALUATED
ADDRESS PROPERTY SIZE
PROPOSED FACIILTY r'd �/� LOCATION OF SITE
Water Supply: On-Site Well Community Public �-
Evaluation By: Auger Boring Pit Cut
FACTORS 2 3
Landscape position
Sloe 7. --
HORIZON I DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH
Texture group
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 RATEI ._�l
SITE CLASSIFICATION: __77— EVALUATED BY: '1443,
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-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
Mineralo¢y
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