121 R Shore Dr DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTE:Issued in Compliance With Article II of G.S.Chapter 130a
Sanitary Sewage Systemss r� Permit Number
Date —Z,-!/ N0 6229
Location
Subdivision Name, Lot:No. Sec-or` lock No.
Lot Size '
_ Howse..1 T,. -I glbf Home L--"" Business Speculation
No. Bedrooms '2 No. Baths 02 No. in Familyj�_
Garbage Disposal YES ❑ 461- Specifications for System:
Auto Dish Washer YES NO ❑ P '
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 — /2?
*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.
91
Final Installation Diagram: System Installed by
q1
A
N�
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.
l DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
&11-14
Soil/Site Evaluation
DATE EVALUATED /52—
NAME �
ADDRESS �j,, PROPERTY SIZE
PROPOSED FACIILTY z' LOCATION OF SITE
Water Supply: On-Site Well Community Publicy
Evaluation By: Auger Boring Pit Cut
FACTORS 1 2 3 4
Landscape position
Sloe % -12
HORIZON I DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH 4V ,74 .9181
Texture group
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 RATEI e I , y , y y.
SITE CLASSIFICATION: EVALUATED BY: /0/1/i
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
Mi neralo[ty
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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.�' Y . APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department
' Environmental Health Section
P. 0. Box 665
Mockoville, NC 27028
1 . Application/Permit Requested By
Mailing Address o X �o
Home Phone In - 3s Business Phone
2. Name on Permit if Different than Above
3. Property Owner if Different than Above 2o
4. Application/Permit For : lC] General Evaluation ttr-S7Tank Installation
S. System to Serve: [) House e--'gobile Home 0 Business
tL] Industry u Other 0 Unknown
6. If house, mobile home: Subdivision Sec. Lot#
No. of People I Dwelling Dimensions
No. of Bedrooms Basement/Plumbing
No. of Bathrooms ` Basement/No Plumbing
0 Washing Machine Fj Dishwasher 0 Garbage Disposai
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: o�blic 0 Private 0 Community
9. Property Dimensions
10. Sewage Disposal Contractoz-
11 . Do you anticipate additions/expansions of the facility this system is
intended to serve? 0 Yes 0 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 the
best of my knowledge, and I under an I am responsible for all —
charges incurred from this appl c n.
1A/1o% G
Date Signature
Directions to Property :
DCHD (10-89)