419 Zimmerman Rd DAVIE COUNTY HEALTH DEPARTMENT !/oo a o a
IMPROVEMENTS PERMIT AND .CERTIFICATE OF COMPLETION 1 :30
*NOTE:Issued in Compliance With Article 11 of G.S.Chapter 130a
Sanitary Sewage Systems Permit Number
Name ��. f� 4, c� J Date `� _ J . � N2 6758
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Location ! ti �,� a �a � w N \ \ 1J - S• ��. ( U j t V
VA
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Subdivision Name Sec. or Block No.
Lot Size !"� `� � House Mobile Home _ Business Speculation
No. Bedrooms D, m. Baths No. in Family _
Garbage Disposal YES ❑ NO ❑ Specifications for System:
Auto Dish Washer` YES ❑-1 NO ❑
Auto Wash Ma.hine YES p- NO ❑
Type Water Supply �) �. _ - XD,
*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.
�G
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 Vi t-K
U�
C)
S
� Y
Certificate of Completion Date 21 9 3
"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.
o3 dr � r
l' APPLICATION FOR SITE EVALUATION/IMPROVEMENTS
OWIE
' Davie County Health Department
Environmental Health Section �0�
P. O. Box 665 APR 2 3 19��
Mocksville, NC 27028
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1'
1. Application/Permit Requested By �, r ) 7 ot-Ln e)
Mailing Address I5 I G SCn Q Sto UL-Y) • LL)i nstdn M nok..l pm . ML -110 3
Home Phoneg19 r1U5 -3819 Business Phone C)
2. Name on Permit if Different than Above
3. Application/Permit for: ❑ General Evaluation N(Septic Tank Installation
4. System to Serve: Q�House ❑ Mobile Home ❑ Place of Public Assembly
❑ Business ❑ Industry ❑ Other ❑ Unknown
5. If house, mobile home: Subdivision Z i")WC✓MOLO I�' .CI., Section Lot#
❑ Basement/Plumbing
No. of People Basement/No Plumbing
No.of Bedrooms Washing Machine
No. of Bathrooms Ld Dishwasher
Dwelling Dimensions_____30 X Cc0 ❑ Garbage Disposal
6. If business, industry, place of public assembly, other: Specify type
No. of People Served i 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 Dimensions541 K 4Qq X. 41 K qs4 Sewage Disposal Contractor —/
9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes LR 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:
gD I 6Du {� -tom ?Q.oPle S Creek d . Cardrh�
�rnc�-� .
Turn l e-r-f- Dn Rcp(e's Cre el . Turnr i`ql�+ o n
f3t.Lr4�n gyp(, Turn l e_, - on Z t mmerm�n d .
Cao ( e:F+ u->-ere row Forks. -prope-riq aJ"
cn c(. Cf roaci on I e--e4 . 71\-e re, i s G- I cx-Le
9p,-e- j ,2_aicb�� fo Property,
�N Q e CL +0 -SC+ Ct-+J rA s? -(i)v- t meCCa e, 10 Meed' i n �
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.
ATE SIGNAVRE
CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY
Ftaondodisposal
ECK ONE: ❑ 1. 1 OWN the property. 22. 1 DO NOT OWN the property.
ked Box #2, the rest of this form MUST be completed by the owner or a person authorized by the owner:
ve consent to the authorized representatiuq-6f the Davie ounty,Health Department to enter upon above described
cated in Davie County and owned by J I m ft0 (A�I r^r�
all testing procedures as necessary to determine aid site's suitability for a ground absorption sewage treatment
system.
DATE S GNATURE
DCHD(12-90)
r DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
NAME SA C Q�f$ DATE EVALUATED
ADDRESS S A PROPERTY SIZE S
PROPOSED FACIILTY `� `� $° LOCATION OF SITE r
Water Supply: On-Site Well L" Community Public
Evaluation By: Auger Boring V Pit -_ Cut
FACTORS I 2 3 4
Landscape position K IR
Sloe % O - G-(�o
HORIZON I DEPTH » 1, tj El
Texture group S c L tL C.L IS C,L_
Consistence ET
-
Structure C R C t? e V
Mineralogy . 1 11
HORIZON II DEPTH L40 o" !b 40
Texture group (% CG C
Consistence F F1 "Z
Structure k A
Mineralogy
HORIZON III DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS S S S S S S 5
RESTRICTIVE HORIZON
SAPROLITE - —
CLASSIFICATION 5 S
LONG-TERM ACCEPTANCE RATE , Li
SITE CLASSIFICATION: \` S 1 EVALUATED BY: _
LONG-TERM ACCEPTANCE RATE: `1 OTHER(S)PRESENT: Ln
REMARKS:
LEGEND
Landscape Position
R-Ridge S-Shoulder L-Linear slope FS-Foot slope N-Nose slope
CC-Concave slopeCV-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
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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