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3213 Hwy 801S 'oke.,,' .5 DAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION *NOTE:Issued in Compliance With Article 11 of G.S.Chapter 130a . SaannitarySe ag Systems �(I� Perm-it Number Name,��C�G �. r G, I Date —.�'�_S ' �/ N27580 Locatio ) � 1 -- I/ Subdivision`Name- Lot No. Sec. or Block No. Lot Size fJ� House 1/ Mobile Home — Business --- Industry No. Bedrooms No. Baths � No. in Family _ Public Assembly Other Garbage Disposal YES ❑ NO Specificationsfor System: Auto Dish Washer YES NO [3 Auto Wash Ma^hine YES NO ❑ ��� r ~r Type Water Supply *This permit Void if sewage systemT�einte alled within 5 years from date of issue. This permit is subject to revocat' d use change. fop / l� .Sd J' .a� a r ; r- s Improvements permit bY *Contact a representative of the Da ie unty Health Department for final inspection of this system between 8:30-9:30 A.M., 1:00-1:30 P.M.or 4:30-5:00 P.M.on day cf completion.Telephone Number:704-634-5985. Final Installation Diagram: System Installed by -0 spa I' Certificate of Completion '– --- Date c '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 R EC E O N/E Environmental Health Section P. O. Box 665 MAY 191994 Mocksville, NC 27028 ,I f -- - - - -------- - 1. Application/Permit Requested By s�&=U en/ I- ds /�e A)/J0 K� Mailing Address P, J/' 50'/ ao 5 / Home Phone dC� I < A)C d 7d o Business Phone 1i3�'d g 2. Name on Permit if Different than Above 3. Application for: ❑General Evaluation Septic Tank Installation Permit 4. System to Serve: House ❑ Mobile Home ❑ Place of Public Assembly ❑ Business ❑ Industry ❑ Other ❑ Unknown 5. If house, mobile home: Subdivision N Section Lot # ❑ Basement/Plumbing No. of People ❑ Basement/No Plumbing No. of Bedrooms ❑ Washing Machine No. of Bathrooms -3 /z ❑ Dishwasher Dwelling Dimensions 0365 sg- f ❑ Garbage Disposal 6. If business, industry, place of public assembly, other: Specify type No. of People Served S No. of Sinks No. of Commodes q No. of Urinals No. of Lavatories No. of Water Coolers No. of Showers Z- Water Usage Figures 7. Type of water supply: JK Public ❑ Private ❑ Community 8. Property Dimensions /. V o c g<S Sewage Disposal Contractor 9. Do you anticipate additions/expansion of the facility this sytem 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. Directions to Property: lrf Ad fi7 `� S��� D'kJ f This is to certify that the information provided is correct to a best f my know) ge, a nders nd I am r o sible for all charges incurred from this ppli77n.5 - r+ / DATE SIGNATURE CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY Fandd ECK ONE: I OWN the property. ❑ 2. 1 DO NOT OWN the property. ked Box #2, the rest of this for MUST be completed by the owner or a person authorized by the owner: ve consent to the authorized representative of the Davie County Health Departure t to enter upon above described cated in Davie County and owned by all testing procedures a necessary to determin said s'e's suitability for round absorption sewage treatment al system. ^/ DATE SIGNATURE DCHD(7/93) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation l NAME �C��� //OGS r" DATE EVALUATED ADDRESS PROPERTY SIZE PROPOSED FACIILTY LOCATION OF SITE _f � Water Supply: On-Site Well Community Public1/ Evaluation By: Auger Boring b/ Pit Cut FACTORS 1 2 3 4 Landscape position Z 4 A_ .C. Sloe Z 'K 3_ HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH r ly 6 Texture group 6_1 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 1 l LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: EVALUATED BY: Al LONG-TERM ACCEPTANCE RATE:: OTHER(S) PRESENT: REMARKS: .S?70�yqP 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 +:lay 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-Firrn 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 ■■■■.■■.■■■..■■.....■...■■■■..■.■■.■■■■■■■■..■..../.■/t.■■ ■■/t.e■ ■■■../.......■...■■.■■■■■.■ .■■■■.■■■.■t..■■■■.�■■■■■■■■■■......■■ ■■.■■■■..■■■■■..........■.■ .■■■■.■■■■.■..■.■.■ ■■■■■■■■■■■■■■■■■■ iiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiii■ii■iiii�i MINN ■■■■.■■■■■■■■■■■■■■■■■..■■..../■■■/.■■■.�■■■■■. ■ ■■■■■.■■■■■ no ■■t■■■■n■.■■.■■■■■■■.../.■.■■./�.....■.�/�.../■■.....//.../. ■■■ ■■/■■■.■.■■■■.■■.■■■■■■■■■■■■■■■ ■■■■■■.ice ■■■■■/.■■■■■■■■■■■■■■t ■.■■■.■■.■.■■■■■.■./.../■■■.......■■.■./.■■■...■■■.■■ ■.■■.■..■.i .................................................. ............... iiiiiiiiiiiiHIiiiiii�iiiiii�iiiiii.�iiiiii�i ...................................... moll■■■■■�i ■'■■C■■M■■■■■■■■ ......■■...n■■■...................... ■■■■.■ ■ ■■ ■■ ■■/...■■ ......■.■...■.n.■..■■■.■..■■■■.■■■■■■ ■ .■ ■.C� ■■C■C■■�=..■.■.■m ■■.■■■■.■■■■..■■■■■..■■t■■/�i�=.....1■■■ ■t..■n .■■.■.■u■■ ■■■■ ■■.■■.■■■.■■■■.■■.■.■■■■■■■�■e■■■■■e■■ ■.I.■e■■ ■■■■■■.■■■■m.■■■ ■■■■■■■.■■.■■.■■■n.■■■.■.■.■■...■■■■. 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