721 Pudding Ridge Rd DAVIE COUNTY HEALTH DEPARTMENT
-IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*_NOTE:Issued in Compliance With Article 11 of G.S.Chapter 130a
Sanitary Sewage Systems , Permit Number
Name— tL� ,� ci�r,,/;;._:,� Date f�c �1 % N2 r 2 Z
Location i°.;" —= �:r '✓ /, , „r-L, .t �/. r ii .r1.;- ,% `/`,,,,' t !F'r�
-Subdivision Name Lot No. Sec. or Block No.
Lot Size House -'"� Mobile Home _ Business Speculation
No. Bedrooms _ No. Baths -fZ2 No. in Family 2 —
Garbage
2_.Garbage Disposal YES NO ❑ Specifications for System:
Auto Dish Washer YES NO ❑ ,, , �:.
Auto Wash Machine 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 .
-- 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
� L
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.
wAPPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section
P. 0. Box 665
Mocksville, NC 27028
1 . Application/Permit Requested By JFRP { R, Wffee
Mailing Address T. V-fOX I&S Rtt4e, PAU, //C. Z704-5
Home Phone „519- 999 - 74,89 Business Phone 1919 - 969-1,0dz i"
2. Name on Permit if Different than Above
3. Property Owner if Different than Above
4. Application/Permit For : General Evaluation 9/s/Tank Installation
5. System to Serve: n House 71 Mobile Home 0 Business
❑ Industry u Other 0 Unknown
6. If house, mobile home: Subdivision Sec. Lot#
No. of People Z Dwelling Dimensions
No. of Bedrooms Basement/Plumbing
No. of Bathrooms Basement/No Plumbing
Washing Machine V/`ishwasher rbage 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
oe
8. Type of water supply: C Public Private 0 Community
9. Property Dimensions 1,6. 4-3 heAas
10 . Sewage Disposal Contractor
11 . Do you anticipate additions/;%Po
ansions of the facility this system is
intended to serve? 0 Yes
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 the
best of my knowledge, and I understand I am responsible for all
charges incurred from this applica on.
9v ,�
Date 9 Signature
Directions to Property:
RUDD114/6 1Q/.DC 6" A1� �. ¢ Me- o
F.mm i n1GTD nl ROAD
`Zt�f�rTS —73 ; 1 'T' �o�,c o47-
7 4T7
DCHD (10-89)
A
1
DAVIE COUNTY HEALTH DEPARTMENT
ENVIRONMENTAL HEALTH SECTION
SITE EVALUATION CONSENT FORM
1. Complete the form below and return to the Davie County Health Department.
2. Carefully follow the procedures as outlined in the enclosed "Information Bulletin."
NOTE:.THE ABOVE MUST BE COMPLETED BEFORE A SANITARIAN WILL BE ABLE TO
BEGIN THE REQUESTED EVALUATION.
DETACH HERE AND RETURN TO: Davie County Health Department, Environmental
Health Section, P. 0. Box 665, Mocksville, N.C. 27028
Davie County Health Department
Environmental Health Section
Site Evaluation Consent Form
LOCATION OF PROPERTY: DATE RECEIVED
7"a).VDIAJ45; RID6LF Ral-l-b (office use only)
yes no 1. 1 am the owner of the above described property.
yes no 2. 1 am not the owner of the above described property, however, I certify that I
have consent from , owner to obtain a
owner's name
site evaluation by the Davie County Health Department for the purpose of
determining the suitability for a ground absorption sewage treatment and
disposal system.
yes no 3. 1 hereby give consent to the authorized representative of the Davie County
Health Department to enter upon the above described property and conduct all
testing procedures as necessary to determine its suitability for a ground
absorption sewage treatment and dis osal system.
I � cy
ATE SIGNATURE
4. 1 hereby authorize the Davie County Health Department to release site
evaluation results from the above described property to the following:
Owner only
Owners designated representative
—Anyone requesting results
— Only those listed below
iz z�l
DATE SIGNATURE
DCHD(11/84)
• DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
NAME �i�L� DATE EVALUATED //�
ADDRESS PROPERTY SIZE Ao
PROPOSED FACIILTY ado. LOCATION OF SITE �p fid
Water Supply: On-Site Well Community Public '
Evaluation By: Auger Boring Pit Cut
FACTORS I 2 3 4
Landscape position G G L L
Slope % .9-
HORIZON
HORIZON I DEPTH
Texture group
Consistence
,Structure
MineralogX
HORIZON II DEPTH
Texture group
Consistence
Structure S6 S
Mineralogy �-
HORIZON III DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION _ 7_17
LONG-TERM ACCEPTANCE RATE
SITE CLASSIFICATION: ' EVALUATED BY:
LONG-TERM ACCEPTANCE RATE: / 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
MineraloL,y
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
T(01-901
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