2593 Hwy 64W DAVIE COUNTY HEALTH DEPARTMENT , D (}
_ IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
-*NOTE:Issued in Compliance With Article II of G.S.Chapter 130a
Sanitary Sewage Systems , / Permit Number
Name�•�F ; i, ,�„ / / �.i< Date N2 6041
Location e"'! r �CrF'
Subdivision Name Lot No. Sec. or Block No.
Lot Size li House ,t --�'� Mobile Home _ Business Speculation
No. Bedrooms No. Baths _ _ No. in Family __
Garbage Disposal YES ❑ NO C2,' ti Specifications for System*
Auto Dish Washer --YES NO ❑ ���0/'�` �
Auto Wash Machine NO ❑ cJ �t� G,
� _
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 Ai
*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 66AI2
r
t
Certificate of Completion IF 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 PERMIT
Davie County Health Department
Environmental Health Section
P. 0. Box 665 ' D SUN
Mockoville, NC 27028 t ���
1 . Application/Permit Requested By Dianne F. Baits
Mailing Address 6176 Ridgecrest Road Winston-Salem, NC 27103
Home Phone 919-766-8890 Business Phone 919-998 6800------
2.
800--2. Name on Permit if Different than Above
3. Property Owner if Different than Above Ruth Ferebee (492-5408)
4. Application/Permit For: 0 General Evaluation S/Tank Installation
S. System to Serve: House D Mobile Home 0 Business
0 Industry u Other 0 Unknown
6. If house, mobile home: Subdivision Sec. Lot#
No. of People . 1 Dwelling Dimensions
No. of Bedrooms 3 - Basement/Plumbing
No. of Bathrooms 2 Basement/No Plumbing
OX Washing Machine � Dishwasher 0 Garbage Disposal
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: 0 Public ( Private 0 Community
9. Property Dimensions 5 acres
10. Sewage Disposal Contractor
11 . Do you anticipate additions/expansions of the facility this system is
intended to serve? 0 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 th4
best of my knowledge, and I understand I am responsible for all
charges incurred from this application.
/(10
Date Signatur
Highway 64 West 5 miles out of Mocksville on the left side of the road. The open
Directions to Property : Pasture past the first house past the Center' Fire Station on
the left. (past the Charlie Barnhart farm)
DCHD (10-89)
DAVIE COUNTY-HEALTH DEPARTMENT
Environmental Health Section
Cl Soil/Site•Evaluation
NAME T DATE EVALUATED 4ro� �
ADDRESS PROPERTY SIZE S/�C
PROPOSED FACIILTY / ►� LOCATION OF SITE G�l
Water Supply: On-Site Well Community Public
Evaluation By: Auger Boring Pit Cut
FACTORS 1 2 3 4
Landscape position L L Slope %
HORIZON I DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH f• '" Q' �`
Texture group
Consistence ,' F% t /Z.-
Structure rA Al a /C
Mineralogy 1.' i n 1
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:
SITE CLASSIFICATION: �,r EVALUATED BY:
LONG-TERM ACCEPTANCE RATE: c 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-Finn 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
i
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/f42
DCHD(01-901
WWI
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