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1067 Williams Rd V'X el DAVIE COUNTY HEALTH DEPARTMENT !o 4moi` IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION *NOTE:Issued in Compliance With Article II of G.S.Chapter 130e Sa�tiEa`ry Sewage Sy�sJems Permit �N er Name ate '7 CN 2 v`7' LopItion k' Subdivision Name Lot No Sec. or Block No. 00 Lot Size House ' Mobile Home Business -- Speculation 1 No. Bedrooms .No. Baths No.'in Family Garbage Disposal YES ❑ NO ❑ Specifications,for 5ystgn Auto Dish Washer YES (p NO ❑ Auto Wash Ma.hine YES [OD NO,0 3 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. r _T 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. or 1:00-1:30 P.M. on day of completion. Telephone Number 704-634-5985. Final Installation Diagram: i System Installed by = � a f '1 1 .. �� 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/IMPROVEMENTS PERMIT Davie County Aealth Department Environmental Health Section n r T P. O. Box 665 Mocksville, NC 27028 1. Application/Permit Re uested By /% Mailing Address elotlll Home Phone g�8'�-��d l� Business Phone st -'-c-- 2. Name on Permit if Different than Above 3. Application/Permit for: ❑ General Evaluation Septic Tank Installation 4. System to Serve: ❑ House "obile Home ❑ Place of Public Assembly ❑ Business ❑ Industry ❑ Other ❑ Unknown 5. If house, mobile home: Subdivision Section Lot# ❑ Basement/Plumbing No. of People ❑ Basement/No Plumbing No. of Bedrooms "ashing Machine No. of Bathrooms ❑ Dishwasher Dwelling Dimensions 00 So . ❑ Garbage Disposal 6. If business, industry, place of public assembly, 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 Water Usage Figures 7. Type of water supply: V-15ublic ❑ Private ❑ Community 8. Property Dimensions ,/0,2 14 c?Dd Sewage Disposal Contractor 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes t 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: o r,Vq 7 C-P` o .►., 4-6 ON e-AA 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. / ,9a DATE SIGNATURE CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY MUST CHECK ONE: 1. 1 OWN the property. ❑ 2. 1 DO NOT OWN the property. [and f you checked Box#2, the rest of this form MUST be completed by the owner or a person authorized by the owner: hereby give consent to the authorized representative of the Davie County Health Department to enter upon above described roperty located in Davie County and owned by o conduct all testing procedures as necessary to determine said site's suitability for a ground absorption sewage treatment disposal system. DATE SIGNATURE DCHD(12-90) �- DAYIE COUNTY HEALTH DEPARTMENT .• ' ' Environmental'Health Section Soil/Site'Evaluation 1 NAME DATE EVALUATED / D - i'2 ADDRESS SAM Q PROPERTY SIZE J d U g O v A PROPOSED FACIILTY Hb LOCATION OF SITE Ljo s3a Water Supply: On-Site Well Community Public Evaluation ByCZ L Auger Boring l.i Pit Cut FACTORS 1 2 3 4 Landscape position -S Sloe Z ' tC -677—a O "g HORIZON I DEPTH 2 2 2 Texture group 3 C .777 Consistence fT I F- F% Structure C 6 k P Mineralogy ! t 1: ) HORIZON II DEPTH 3 6 ` 36 ` " 6 Texture group S Q. Consistence R H Structure P Mineralogy1 �;1 HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS $ ,S Z S S RESTRICTIVE HORIZON — -- SAPROLITE - CLASSIFICATION S 5 _S • S ' LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: v 'S EVALUATED BY: �GNl,� 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 clays C-Clay CONSISTENCE Moist VFR-Very friable FR-Friable FI-Film 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 freIe 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 ■■■■■.■■■■.■■...■■■■■■.■■■■/■■■■■■■■.....■.■■■..■■■■Neve/■■ Pfeil ■■ iiii■�iiiiiiiiiiiiiiiiisiiii�iiiii=i■�iiii�■iiii�■iiiii■iiiiiiii�.i ENO .................................................................. UNMEM:: ::NNEN MENN:ii:::::: :::::: M:::::S3::::EN"EM:::: ......................................... ■■e■■■■e.m■e.e■.■■.■■■■■ ONE mom ENO ■. ■t■. ■■e■.■■ ■e:e::..�.■■■■■■■■■.■■/..■■■.:..�....■■ .■.■e■.. /■.e■■.■■.■■ ■■■■ ►l.■...■......■.....■.c_.�L.■.i■.■..■■■■■■■.■■�■�■■m■■■.■.■C■■■■■■ ■ cilia.■.....■■...■■■..■►� e..■...■...■■.■...u..■■■ .■■■t■.......... 17l�7/..■■..■ .._■��.■11■Rr>\..■■.■■...NC�.........�■.■...■ ■■■■.■.■ uphi:!1■■■.iwi.i.i..�:.��S,�:Z711.■■.■■ ■/A1�:�.■■■.■■.. ■■■■■■..■■■.■■■■■ ME ■'.■■.■■.■■.■.■■■■.■.■■.■■■■■.■■N■.■■.■i■■■■■■■ell■■.■..■.■■■■■■■.■ Davie County Health Department 19. `i§k Environmental Health Section ` P.O.Box 848 210 Hospital Street Courier#:09-40-06 15 t f Mocksville,NC 27028 Phone:(336),-753-6780 Fam(336)-753.1680 ON-SITE-WASTEWATER CERTIFICATION (Cheri One)CReaceRemodeling onnectionn c Name: c' Phone Number (Home) Mailing Address: e Tt1J orn 6,LaL- RC(q (Work) VAI (\5im- koAek11UC- . Detailed Directions'To Site: -A'-�Ay Ire! lQOQ . /"njAA - on fa 80(—S 1 ,� atrrn. r Y i / 1Wur"S Property Address;.LOA .2, 1 E's 4n,4 d.4 x`7-1? $1'1 U �3 Le nq(. Please Fiff In The Foupwi ag information About The EXISTING Facility: Name System Installed Under: Type Of Facility: to v)A Wa6 Date System Installed(Mouth/Date/Year): Number Of Bedrooms: Number Of People: Is The Facility Currently Vacant? Yes No If Yes,For How Long? Any Known Problems? Yes No If Yes,Explain: Please Fill In The Following Information About The NEW Facility: Type Of Facility: C. Number Of Bedrooms: Number of People Pool Size: o a Garage Size: Other: Requested By:_ U 010 Date Requested: (Si ature) For Environmental Health Office Use Only ®rovedDisapproved .y& s Environmental Health Specialist Date:. *The signing of this form by the Environmental Health Staff is in no way intended,nor should be taken as a guarantee (extended or limited)that the on-site wastewater system will function properly for any given period of time. Payment: Cash Check Money Order # Amount:$ Date: Paid By: Received By: Account#: Invoice#: -f;Q