139 Pete Foster Rd_ Xa
Dvl vio
c: "s DAVIE COUNTY HEALTH DEPARTMENT JUS
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
'NOTE:Issued in Compliance With Article II of G.S.Chapter 130a 8A
Sanitary Sewage Systems _ - Permit Number
c��,� .��� ---Date 5 11 - 15
Name N2 8 012_
Location
Subdivision Lot No. Sec. or Block No.
Lot Size '�A House — Mobile Home — V _Business _— Industry
No. Bedrooms —_.No. Baths _ - No. in Family — Public Assembly Other
Garbage Disposal YES ❑ NO Qf Specifications for System:
Auto Dish Washer YES ❑ NO C)o ca z) ' �
Auto Wash Ma^hine YES v❑� NO ❑ ,,'
Type Water Supply _-- --- S�
'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
I
ATTENTION: YOUR,SEPTIC SYSTEM CONTRACTOR MUST SEE THIS PERMIT/LAYOUT BEFORE INSTALLING THIS
SYSTEM. 1�.
n.
� T
xNQ
B '
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.,
1:00-1:30 P.M. or 4:30-5:00 P.M.on day of completion.Telephone Number: 704-634-5985.
Final Installation Diagram: System Installed by1 it
e'' `
�
?s�Q1175,
z
all 3
------------
�1
Alt
a
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. ,
40
J DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*.NOTE:Issued in Compliance With Article 11 of G.S.Chapter 130a r�a
7Sanitary Sewage Systems � t -
Permit Number
Name- i"l ,t � C� � � � a- _-- Date t I N2 8012
Location �-'� �'�c.a �`�� � � `��-, — .. � �.:. '; ?jt:
hr
Subdivision Name Lot No,. J Sec. or Block No.
Lot Sized r`�-f== - — House — Mobile Home —v— Business _— Industry
No. Bedrooms No. Baths —2i-- No. in Family ^' _ Public Assembly Other
Garbage Disposal YES ❑ NO 2/ Specifications for System:
Auto Dish Washer YES ❑ NO CO/
Auto Wash Ma^hine YES W NO ❑ a
Type Water Supply _ `..)J �'w ----- --- X. :a, l { 5"��r `��•
� 1
*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
ATTENTION: YOUR SEPTIC SYSTEM CONTRACTOR MUST SEE THIS PERMIT/LAYOUT BEFORE INSTALLING THIS
SYSTEM,
i
i } -f-
Wo m-, ?
-r,
�, TM
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.,
1:00-1:30 P.M. or 4:30-5:00 P.M.on day of completion.Telephone Number: 704-634-5985. p
Final Installation Diagram: System Installed by �''"s`
aF�ll�S
r
I�
f`Afi
s. -ix
i
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. r
r + '
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PE
Davie County Health Department
Environmental Health Section
P. O. Box 665
Mocksville, NC 27028
J, tiii��ii 1 1
1. Application/Permit Requested,By a m 4 r
Mailing Address 0 x nSf 31 Q Home Phone�J�71� Zl
Rr�11,301 1 �►C- ZZ13Business Phone
2. Name on Permit if Different than Above
3. Application for: ❑General Evaluation g Septic Tank installation Permit
4. System to Serve: ❑ House Te(Mobile Home ❑ Place of Public Assembly
❑ Business ❑ Industry ❑ Other ❑ Unknown
5. If house, mobile home: Subdivision Section Lot #
❑ Basement/Plumbing
No. of People 3 ❑ Basement/No Plumbing
No. of Bedrooms 3 X Washing Machine
No. of Bathrooms .12 ❑ Dishwasher
Dwelling Dimensions X ❑ 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: ❑ Public Private ❑ Community
✓ 8. Property Dimensions 31,cre Sewage Disposal Contractor
9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes ANo
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:
�rooc�'S✓,t1
i,r , S kv�C c-a 44S rA . 0 114..E
-FU�r n -L d r� lie+e t—os+� 1241 .
cL�.C�w� r
LJ-WedY\ o-I raw a;� p;�c- �rca5
1 1- L.ak�. �a,n ca.11 awr.Qc- f r-la(-i'hc� R�1otilakr/4+ �3N—a-us) �"
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.
DATE SIGNATURE
CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY
MUST CHECK ONE: ❑ 1. I OWN the property. X 2. 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 Davieounty Health Department to enter upon above described
property located in Davie County and owned by ��214 A 1 da:,ri #o u PL
to conduct all testing procedures as necessary to determine said site's suitability for a ground absorption sewage treatment
and disposal system.
- -5"-/- %-.1z: I�Z-
DATE SIGNATURE
DCHD(1193)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
\ ` l Soil/Site Evaluation 1
NAME AR� W c DATE EVALUATED
3
ADDRESS ��A`��� PROPERTY SIZE
PROPOSED FACIILTY � ��"�� LOCATION OF SITE \\4
Water Supply: On-Site Well _ Community Public
Evaluation By..' l _ Auger Boringy Pit Cut
FACTORS 1 1 2 3 4
Landscape position S S
Sloe % 8^16° 8'-16° $' -115 8 -
HORIZON I DEPTH
Texture group C L L..
Consistence 'T
Structure R C Q C V
Mineralogy ' t
HORIZON II DEPTH �I Z ' 1'1 '' `I
Texture group C
Consistence V— S, -�-
Structure
Mineralogy ► ;1 I ,
HORIZON III DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
.Mineralogy
SOIL WETNESS S r s S;S
RESTRICTIVE HORIZON — --
SAPROLITE --
CLASSIFICATION vs. S. ;S_, Its
LONG-TERM ACCEPTANCE RATE
SITE CLASSIFICATION: �S- EVALUATED BY:
LONG-TERM ACCEPTANCE RATE: 4 OTHER(S) PRESENT: No�o a
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 'Aay loam SIL-Silty loam CL-Clay loam SCL-Sandy clay loam
SC-Sandy clay SIC-Silty clay C-Clay
CONSISTENCE
Moist
VFR-V+_-.-y 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
.3C--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
■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■
■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■
■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■ ■■■■■■■■■■■■■
..........................................C...■■ENNOMM.■■■■......
.................................................... .............
■■■■■......■..■■■■.■■■.■■■■ ■O..■.■�1rir�lU.l.■■... MEMOM■M.C■MMMMM■■
■■■M.■.■■..■■■.■■M■■.■■M■MMC■.■.■■rel►�w■■�•.■...e.C■■■■C..e■ ■■.■...■
■..■.■■M■■■M.M■..■..MN.E.MO■■M....t�/�I�MMO\`■MMM ■N.N.OH ■■■M.■OO■
..■M■■M■■■MM■.M......MM..M■E■■...■■N,�N.■MMI,■.■C�•C■=■..CCCE■.■.■ICN■
OEM ■
■■■■.■■■■■EM.MN■.M■■...M.M■■..■.M■■�uME. C ONO ■..■■... ■■
■..■■M.■■■■■MN■■■.■■■■■....■■■■■■■E.N.■e.■EE.e.�.=■.■..EN..M■..e■
■■■■..■■■.■ME■E■■M..MM.■■.■MM.E■■■=.CE..E■MC...H.e...■MC.C■■■.■C
NONE................................�.......N�....M■N.......... ONO
MONNEEN
■■■■■M■..s.N..■.■N■.MH.■■■■■■E■...H.....■EM.. M... ■...■■■.IN
MMMMMmMMMMM ONO MMMMMMl
..■■.■■■H....■E■■............................... ..■. MMMMM■
■..MM..■■....MN■■M■.M■.MMEM■.■■..M.MM■.M..MM■■MCC CCM■=MN■■M■M.
■..■M.E.■Ne■E.M.■■E■MM■■■■M■■MMIC■■ME■.■■ ■M■.M ■ ■. ■■ .■.MMN■
■....■....■.■...■...Eu....■.... =a ON.uN■.NHNNMMM.NM .■■M.EMENMENEMEM
.■
.■■ NON■OE.■u■HM.■1�--=�--moommmmmm
MMEMENSOMEN —_---------__�.�.�,
■MMMMMMMM■■MOO.■OC.00.I�!"1■Mt��M■.O� t■��� eM�CC�J�C�.' OEM �.■■■■
■■■■E.E.■.■MMM■MM .■.. bH.■\1 11■■1 _ 1■, l \_ IOMEN . ■ NM M�■ EMENSON MEN �
■■O.N. MME.N.
MEMO NONE NONE t,lt■ ■ MMNo . 00NO■E
MMMMMMMMMM.M"MMMMM,,, P ..E..�EMME I1� ■ ■SMIN■.M ■■■MME
�•W� OMMMMMMMM
�.■■NE MMMMM■
Eiiiamm
MMMMMMM
ONE
.■..■M.MM■■M■■M■MMCMMHMMEM■EM.OME..M.eME■M.■=e■r■►Y1JoE■E■.■�■.• / ■ Na■Me■■NECHE.H.E■
MENENOMMMOMNNEM■■ f ■ ■ MENOM..
■MMMMM■ ■ ■MMMHMMMMMM■W \1n ■
1
■■■■■M■ ■ NUOMMMOONu ■O
IN
■■M■■ ■■■■■■ummmN ■■ momONE
■■■■E■ME■ ■M■■■■MMMMw ■■ E ■.M■E ■ MO.C....NE
N■C.O
ME
mom
8 rh
MENN
■■■■MMM■■■■■.■■■■M■NEM■■ME..■■■M►■■■■M. COMOOHO■■■NE■HMMM■■M■ MO.N. .,
■■■ . . ■■■■ ■MM.■M
■H.■■■.. IN ..
■M
mm MMMMMMMMMMM
■�
■■■.... ■EECC■..E.N■.0■E.■■..`!■.0 ■■ IME ■ ■H�■
■■■.■.■■■■E■■■■E■E.■■■■■■■■■EE■.ENE_ . N CCCCMMCC
■..■.■.■EEM■■M.ME.EME.NE.N■N■MM.■■M■.MMM�
MMMMMWIIlllIIlM
■MM■HMMMM■■M■MMNH■■...■■■...■■MMMMMMM ■ ■ ■I�1 \i. ■MOH■■■N■ON■
■■MO..■N■.EMENNEONENO■NOMM■NEE■�M.CCC `�•C;1 `/= .■.....ONE
■■ MMMMMMM -- MM■MMMM■MMME■.N.. ■■EMM u■EMEOHN■�
MMCMMMMMMECE.CC■MON■EEM■NO■■MM■OMNOpmam
E.E■ ■■EE■M
mom..Mr■ .MOMEMO ■EMM.■ ■MMM■MMMM■ EME�MC■■N.E.
■■■EME ■MMM�mom�O■EMENCMENEMUOO . EN■E ■H■MM■MM■
MEN no ■ EO OMNI . MMM■MMMM■MMOEM M■ ■■M CM ■■N.M■MMMMMMM■MM
..MEECC■.MEMO■ECNEMON■EMONE Elmo IN
■■....uO■E■/.MMMENN■MM.■OMMENMIUu■MC■N■.NE.■■■■.......■MMM.■■■.
...........H■EE.HOE■.OE■.N■H■■■E...�...■■■..E..■EO...H■■■..■■
..■M.■■.■.................................■M■■M■M.■EN■■■■mmKMMMMM .■N■.■■.■
■M■.M■.MM■M.IN 'EME■■■■■■■■EI=N■MEN.MMM■MMMMMM■MM■MMMMM■MMM■■......■
■ME.�■.■■■..E..EO.■MMMMMMM■ MENOM■■■EM�■M■MMMM.EMMMMMMMMMMM.■NN■MMEMEN ■■M.■�.
� .■.......■ENMEN N■■■N■■■■NONN■■ ■■■EE■.N■M■MMMM■■N■■■.■E■..NN■■■
I■.... ■■ENN■MEN NNMN■OE■■■.■■EH..E■E . ....■■.....■.■MON■.NM■N�