260 Pine Forest Ln DAVIE COUNTY HEALTH DEPARTMENT
1.
'11 00•crU
-- IMPROVEMENTS PERMIT AND CERTIFICATE `OF COMPLETION ` 7
'NDTE:Issued in Compliance With Article IIPIG.S Chapter 130a
,Sanitary Sewage Systems 60 L�-e r Permit Number
l � 11 . �3
Name 1 N �1 A VJ t`� . (L. Date �o- l - 7 3 5 7
Location - 0�. N `� ���c,� o+� W:)yN � y,w, V A ti p-V- _ Q��
11 -. L ca.•y 1 R,_` :` rra, - <. .. S 111 .r�+.,�\�rrn:' rJi�c.
Subdivision Name Lot No. Seca or Block No.
Lot Size i ' House Mobile Home - 1-� Business —_ Industry
t
No. Bedrooms _.aVo. Baths Na in Family _ "''Public Assembly Other
Garbage Disposal YES"C] NO [ -
Specifications for System:
,.Auto bish Washer YES pf"1NO ❑ f Lx�U c ,�
Auto Wash Ma thine YES NO ❑ q,
Type Water Supply
'This permit Void if sewage system described below is not installed within ye s from date of issue.
This permit is subject to revocation if-,site plans or the intended use'chang '
- t -
! ) 'moi n
------------------
:
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 by � � �'�` ►tires
g
FvEnt
C
!i
5
Certificate of Completion C � " St 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. $
now
DAVIE COUNTY HEALTH DEPARTMENT
OD
IMPROVEMENTS PERMIT AND CERTIFICATE "OF COMPLETION '
NOTE:Issued in Compliance With Article II�G.S,Chapter 130a ;
Sanitary Sewage Systems 6Z ' :1-+-c-" c Permit Number
Name r 1 P"1 �.Q w V'�� R, Date � �- A - 93 1�0
M - 7359
Location O 2), VA\N +3 00 b A b
l
Vj"'�k I ey, �-ft T
�r—
Subdivision Name Lot No. Seca or Block No.
Lot Size�' �?�� House Mobile Home _ �'�— Business Industry
No. Bedrooms 3 No. Baths _ No. in Family _ Public Assembly Other
Garbage Disposal YES`E] NO [ Specifications for System:
,.Auto Dish Washer YES p1'�NO E] /
Auto Wash Ma thine YES L� NO ❑ f. 4
Type Water Supply
*This permit Void if sewage system described below is not installed within ye s from.date of issue.
This permit is subject to revocation if-.site plans or the intended use'chang
�S
{
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 by � � *'t��
g
Certificate of Completion � �� .�X�t Date /
*The signing of this certificate shall indicate that the system described above has been installed in compliance wit
hl .
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 EVALUATIONIIMPROVEMENTS PERMIT
i�l�
Davie County Health Department �n
Environmental Health Section aV
,G (� ED
4 r' f I' P.O. Box 665 �t'
Mocksville, NC 27028 OCT 14 {t�M
�� • '
----------------
1. Application/Permit Requested By Dianna
Mailing Addresses a, �i , C ( Home Phone� 7'���5
Dc' b My � _�_']D�� Business Phone 919-Wo-7055
2. Name on Permit if Different than Above
3. Application for., a General Evaluation 19 Septic Tank Installation Permit
4. System to Serve: ❑ douse CC Mobile Home ❑ Place of Public Assembly
❑ Business ❑ Industry ❑ Other ❑ Unknown
5. If house, mobile home: Subdivision Section Lot #
❑ Basement/Plumbing
No. of People J ❑ Basement/No Plumbing
No.of Bedrooms 3 ER Washing Machine
No.of Bathrooms Z I4 Dishwasher
Dwelling Dimensions�1oo ❑ Garbage Disposal
6. If business, industry, place of public assembly,other: Specify type
No.of People Served 3 No.of Sinks
No.of Commodes No.of Urinals {
No.of Lavatories No. of Water Coolers
No.of Showers Z Water Usage Figures
7. Type of water supply: ❑ Public Private ❑ Community
8. Property Dimensions .:X l RCerS Sewage Disposal Contractor
9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes C3 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,:
:rqo\,] - ?-X4 n mA kap Aieis Cat gow-d -�O DoLv i e.
kD&m n 4t e,�V cn SkaJ I I noII - 4wrn
�e�� Fore rood � 42rA 0-0-, c�ra`ve��
. or ��n� .
5�-��� �o r►9h� - mvJ lob ts 5�'o.�h� -thcovgh wc�cds
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.
10-1n-
DATE SIGNATURE
CONSENT FOR SITE EVALUATION IQ BE DONE QIN ABOVE DESCRIBED PROPERTY
MUST CHECK ONE: 1. 1 OWN the property. ❑ 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 Davie County Health Department to enter upon above described
property located in Davie County and owned by
to conduct all testing procedures as necessary to determine said site's suitability for a ground absorption sewage treatment
and disposal system.
1040g)A111111
DATE SIGNATURE
ocHQpla�
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DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
NAME 1,)\�N �� '� W A� �' DATE EVALUATED
Q `LIQ PROPERTY SIZE
ADDRESS .�
PROPOSED FACIILTY LOCATION OF SITE
Water Supply: On-Site Well Community Public
Evaluation By�_�-L' Auger Boring Pit Cut
FACTORS 1 2 3 4
Landscape position S 5
Slope Z -\ -11511 C6 -\s
HORIZON I DEPTH ) 2" 12" 1,). ' 757
Texture group L
Consistence
Structure , C� `T
Mineralogy "N \'•\ \` 1
HORIZON II DEPTH
Texture groupC
Consistence �-
Structure
Mineralogy
HORIZON III DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy \
SOIL WETNESS Ss S s' s S sS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE \i
SITE CLASSIFICATION: _- \� S- EVALUATED BY: o
LONG-TERM ACCEPTANCE RATE: l� OTHER(S) PRESENT: °(41:
REMARKS: �. C�. /��' - �'L"R,�,
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 'V'
SC-Single g grain M-Massive CR-Crumb GR-Granular ABK-Angular locky
SBK-Subangular blocky PL-Platy PR-Prismatic
c
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
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