142 Sam Cope Rd , a -. . o.,,.-: „e .. >---•
DAVIE COUNTY HEALTH DEPARTMENT /CU• o 0
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
i NOTE:Issued in Compliance With Article II of G.S.Chapter 130a
Sanitary Sewage Systems > ^ Li
Permit Number
Name � Qrni.: Date ` - N2 17
Location 'Z�R Q) 1 lk �'. n1 0 U(v
Subdivision Name Lot No. Sec. or Block No.
Lot Size0 House V Mobile Home _ Business _— Industry
No. Bedrooms 3_-'.No. Baths _ _ No. in Family _ Public Assembly Other
Garbage Disposal YES Cer NO ❑ Specifications f r System: _
Auto Dish Washer YES 21, NO E] ,/(� a .c� , �h Q -�>4�c
Auto Wash Ma shine YES; NO ❑ V v all
CvyN � >t
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. Ica��`
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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.
i ,
Final Installation Diagra : _I �o�� System Installed by ,,`
SPe�
Y` Ifl
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ion
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.
APPLICATION FOR SITE EVALUATION/IMPROVEMENTrBEEENISSUED.
���
Davie County Health Department Environmental Health SectionP. 0. Box 665 , lQ�Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT H E.
P 04S 11-3
Home Phone
1. Permit Requested B &,kIQ„_Business Phone 0 Q -!5-1on
2. Address
3. Property Owner if Different than Above k• A�f..
Address DA
4. Permit To: a) Install Alter Repair 1
b) Privy Conventional-Y,Other Type
Ground Absorption
c) Sub-Division IJjA —Sec. Lot No.
5. System used to serve what type facility: Housed Mobile Home Business
IndustryOther
b) Number of people '�-
6. a}If house or mobile home, state size of home and number of rooms.
House Dimensions kk-00 D
Bed Rooms—Bath Rooms Den w/Closet_._1y J�
b) If Business, Industry or Other, State: Number of persons served A
What type business, etc. mi A
Estimate amount of waste daily (24 hours) A,/A
7. Number and type of water-using fixtures:
commodes urinals 411A garbage disposal
lavatory showers washing machine
dishwasher ✓ sinks
8. a) Type water supply: PublicPrivate Community
b) Has the water supply system been approved? Yes No
9. a) Property Dimensions_ &O o X ao 0
b) Land area designated to building site
c) Sewage Disposal Contractor —N I A
10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve? 1,3 o
What type?
This is to certify that the information is correct to the best of my knowledge.
4
oA- 0a,0 -CA
Date Owne ignt re
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
cq, -_ N�k GJAA.sL .
J
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DCHD(6.82)
' DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
NAME bl� d q\ y��'�- DATE EVALUATED
ADDRESS SQ PROPERTY SIZE rwt k
PROPOSED FACIILTY9`' LOCATION OF SITE
Water Supply: On-Site Well
Community Public
Evaluation By:�tk_N—Auger Boring Pit Cut
FACTORS 1 2 3 4
Landscape position _S S _S 77
Sloe % T Ib- -b
HORIZON I DEPTH 12t' "` 1- to
Texture group S CL C k.- M'L_
Consistence
Structure 1Z
Mineralogyl \'
HORIZON II DEPTH
Texture group C
Consistence VrL
Structure Q
Mineralogy
HORIZON III DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON --
SAPROLITE -- ,—
CLASSIFICATION ,S S .S
LONG-TERM ACCEPTANCE RATE �c 1 '4 r
SITE CLASSIFICATION: ` J' EVALUATED BY:
LONG-TERM ACCEPTANCE RATE:: OTHER(S) PRESENT:
REMARKS: . V- _.�
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 :lay 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
Mineralosty
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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