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DAVIE COUNTY HEALTH DEPARTMENT 2 H
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION IDw�
*NOTE:Issued in Compliance With Article II of G.S.Chapter 130a
ystents ` PermitNumberOK--
Namegnitar)�S�ewaga
to i ( �Fb 4 ��114112,4" Date bl NO V 9 1�
Location
Subdivision Name Lot No. Sec. or Block No.
Lot SizeHouse Mobile Home ,r Business Speculation
1
No. Bedrooms `� No. Baths No. in Family —
Garbage Disposal YES ❑ NO ,p' Specifications forSystem:
Auto Dish Washer YESNO E]
Auto Wash Ma:hive YES � NO ❑
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.
�-L/,
i
Rf
r
��i9✓c: J ��r,.u r
/�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 .
�Lji�1,
F
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.
�� s• eCr ��
APLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department
'
K�P
Environmental Health Section
P. 0. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone
1. Permit Reques d By &_77 Business Phone -
2. Address L- �e
3. Property Owner if Different than Above
Address
4. Permit To: a) Install Alter Repair
b) Privy Conventional ✓Other Type
Ground Absorption
c) Sub-Division Sec. Lot No.
5. System used to serve what type facility: House 'Mobile Home Bs
/ IndustryOther
b) Number of people !f-
6. a)If house or mobile home, state size of ho pe and number of rooms.
House Dimensions --5�� d �
Bed Rooms Bath Rooms Den Den w/Closet
b) If Business, Industry or Other, State: Number of persons served
What type business, etc.
Estimate amount of waste daily (24 hours)
7. Number and type of water-using fixtures:
commodes urinals garbage disposal
lavatory showers _�______- washing machine-
dishwashers
achine
t ..
dishwashersinks
8. a) Type water supply: Public Private Co unity
b) Has the water suppl *1Id. en approved? Yes No
9. a) Property Dimension en
b) Land area designated to building site eT
c) Sewage Disposal Contractor .
10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve?
What type?
This is to certify that the i formation is Corr o the b knowledge.
r Z/' -1
Date Owner Signature
OWNER IS SOLELY RE ONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
T�
J�
L=7
DCHD(8.82)
: DAVIE COUNTY HEALTH DEPARTMENT
' Environmental Health Section
Soil/Site Evaluation
NAME //n /Y DATE EVALUATED V 7
ADDRESS PROPERTY SIZE
PROPOSED FACIILTY LOCATION OF SITE P��/i�1
Water Supply: On-Site Well Community Public—
Evaluation By: Auger Boring Pit Cut
FACTORS 1 2 3 4
Landscape position
Sloe % — 2
HORIZON I DEPTH Y
Texture group tG S%1_1
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 1 .17 1
SITE CLASSIFICATION: EVALUATED BY:
LONG-TERM ACCEPTANCE RATE: 1 -54 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¢►
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
D(01-901
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Davie County NealtFr De artment
and .glome Nealtl yency
210 HOSPITAL STREET/P.O.BOX 665
MOCKSVILLE.N.C. 27028
PHONE:(704)634-5985
August 27, 1991
Potts Realty
Attn: Roy Potts
P. 0. Box 11
Advance, HC 27006
Re: 3 Site Evaluations
Redland Road at I-40
Dear Realtor:
As requested, a representative from this office visited the aforementioned
sites on August 22, 1991. The sites were found provisionally suitable for the
installation of a ground absorption sewage system on each tract. The location
of each house must be staked before permits can be issued.
If you have any questions, please feel free to contact this office.
Sincerely,
Robert B. Hall, Jr. , R.S.
Environmental Health Section
RH/wd
Enclosures