264 Potters Ridge Dr Lot 7 � - �qi -v✓Y-..�--V^'"- - �.-r-- �,�-�....,,,.J�.�^^•�.�. __fir^."�^'�-�✓�✓'----.�.._-, w-a�.....y.��.v:+—`b+ •- -
DAVIE COUNTY HEALTH DEPARTMENT9 9. r 1p
i
IMPROVEMENTS PERMIT AND 'CERTIFICATE OF COMPLETION
r 'NOTE:Issued in Compliance With Article 11 of G.S.Chapter 130a
Permit Number
-' Sanitary Sewage Systems •- � -
Name t.It?74D/a/t 1 7
w 8 5
Location
' L7r':lJ/.•r � i'f/�J '� / y%f/' ;,,s'.�/ /c"T // 'N'/ya'C" /'i" / !' � � �iI
Subdivision Name� L A. 111-e-- Lot No. Sec.-or Block No.
Lot Size aP�' �� House Mobile,Home ---_ Business __ . Industry
No. Bedrooms F '— '�.No. Baths __ No. in Family f — Public Assembly - Other =
Garbage Disposal YES-'❑ NO 0' Specifications„ for System:
Auto Dish Washer YES NO ❑
Auto Wash.Ma^hine YES $ NO r-1
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 tolirevocation if site plans of the,intended use change,
ATTENTION: YOUR SEPTIC SYSTEM CONTRACTOR MUST SEE THIS PERMIT/LAYOUT BEFORE INSTALLING THIS'
SYSTEM.
Id
Improvements permit by L!—
l; I
tt*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: 7o4-634-5985:
r Final Installation Diagram: System Installed by
- , � , . �•,.K � �}}5 W to nd't Co i.,�.'�'
�:�,�.gib. .. •, .�
fr
IN
�. II
3
o' .
II Certificate of Completion �_ _ Date
The signing�af-t•Wis 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 peri�f d.of.time. V '
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PER 0
Davie County Health Department
Environmental Health Section
P. O. Box 665 2
Mocksville, NC 27028
1. Application/Permit Requested By on C's lJorl..A IC( ISO pcl �(l
Mailing Address eln ,�,14Ab ` 7A,?a Home Phone L9«)
Business Phone &d)
2. Name on Permit if Different than Above
3. Application for: ❑General Evaluation 'Septic Tank Installation Permit
4. System to Serve: P1 House ❑ Mobile Home ❑ Place of Public Assembly
❑ Business ❑ Industry n ❑ Other ❑ Unknown
5. If house, mobile home: Subdivision L%T��r5 l�i& e-- Section ,� Lot # 57
2?15isement/Plumbing
No. of People ❑ Basement/No Plumbing
No. of Bedrooms 3 EZ,-Wishing Machine
No. of Bathrooms G� ishwasher
Dwelling Dimensions_60 X SW ❑ 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: Q Public ❑ Private ❑ Community
8. Property Dimensions Sewage Disposal Contractor
9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes E�-f4o
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:
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.
DATE SIGNAT
CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY
Fandd
ECK ONE: 1. I OWN the property. ❑ 2. I 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 representative of the Davie County Health Department to enter upon above described
cated in Davie County and owned by
all testing procedures as necessary to determine said site's suitability for a ground absorption sewage treatment
al system.
-oZ 9 -9S
DATE SIGNATURE
DCHD(1193)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation /
NAME X�D�//I DATE EVALUATED 'c/%//95�
ADDRESS ��// PROPERTY SIZE S/qG
PROPOSED FACIILTY / /AS LOCATION OF SITE %�/ C �✓
Water Supply: On-Site Well i / _ Community Public
c
Evaluation By: Auger Boring i/ Pit Cut
FACTORS 1 1 2 3 4
Landscape position
Slope Z
HORIZON I DEPTH
Texture group CL rX G
Consistence
Structure
Mineralogy
HORIZON II DEPTH d " aS"
Texture group C
Consistence i
Structure
Mineralogy
HORIZON III DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION ,T
LONG-TERM ACCEPTANCE RATE /y j�
SITE CLASSIFICATION: !rte EVALUATED BY: _ z%,//— ,(;/T/45,
LONG-TERM ACCEPTANCE/l
ANCE�� RATE: ��OTHERR(S) PRESENT:
1,2
REMARKS: P_L r0 Ib- ('yF/.f.'zl�� 1 ,0/4zl/Y4:e 0 " 4 .1
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-V-_�-y 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
3C--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
■1 ..■.■■■■.■■■■■■■■■■■■■►/■■■■■.■■■■■.Er.
OMNI ■ ■ ■E. ,.M■.■. ■■
ON MEMONOMMENNEEMES
MMMMMMMMMMMMMMI SEEN
■■��r�■■■■.■■■.........c,.■■■■■■■■..�s■ �■__�.. ■NH
M■■■■MEM ■ No
..��.......................................... ON
■.V■M■■N.■■■■■■■■■■M■Oh...■■..N■■■■■HN ME
MEW i:::: MEN
■■O■■■■■■■.■.■■.■■■.■■■■■■E■■.■■ ■■■■...■ N
■■■■..■■■■M.■.■■■■■■.N■■■..■■■■■■.N■■■/■.■■.OSA■■■■ MEMM■ME■■■M
..................■■■MN■E.■E.■■.■■E■■■N■......F." ME:MEMS■MMME.O:
................................,�..............�_
NEE .N......0
mom'E�=ii::::::::
■..■■■■■M■.■■■■■ ■■■■N■■.■■■■.. ■■■■N■■■NN■■N■■■■■■:■■■■■■■.
.::: 0 ME EMOMMUMME ME
■EEEEE..G. ..N :t::::0
.■■.■■■■■■E..■■■■.■■...■■■■■■■MN
I
... . ...�■■■■■■no N I IN I MEN :
NOON■■EN■■■■ ■■. .■ M. ...■■■■■.:
N■/■ ■■■■ ■ N ■MMMME
......■E..NE.EEE■EEE■EEEE:EM■■M■NMEE . EEE ■MMOM■
....■■■■■■■■■.E■■■■...■■N■■■■■■■■ .■ ■N . MMEMMMO■
.■■■■E..■.■■NE■■■■E■■■■M■NOES■ME N .. ........
■M■.■■■■■■O.■N■■■■ ■■■■■.■S■.■■:: ::E ' ii MEENEM 0
MEMEMO"O:S:::'::SS=SSS■SSSS■ NEE MNoE
■■MEME::E■NNO■■N:■■:::NN■■E M: :■EEOM::
::MMIMME MOON
■■■./■.■■■.�■■■■■N■M■ OMMME
■M■■■MN�■ N ■■ NEM■O■EMEMEMEMEME �
::::::'■'■::::■NOH::�:■�:::: IN
:::N: ■ �E ON■■■■
■■■■■■■N■■MEN:N'N'�::::��:::' N N:�NNN::��
■.■MEN■ M.■E
MEND■.M ::0=i:::::::.':N:::■': ■ N M MI 0
■■. ■■.
:::::::..:C'..:::::::::::::::::::C ::C:""
...........:..............■..EEM. .O M■
.......■■■■■O■■■■O■■■■■■■■N■■■■ ■E■■M■■ MENMS•■M■
OS'O EMEME ■SSSS'■ ■ ... MMMM: MMMMMMMMMMMIRMMMMMIMMMRMM E .'
..........
M so M NNE EEO MUMMUMMUMMER 0 MOMMMMMEMEM
••ONES :M MEMS:MEMMOMMMEMOMM:N..:: :: : :: ::::uEON
.■■■■■N.■■■■■N■■■■■■M■M■MOMME
............................................................■....■
:AOS:S:::::N:::::SSS:::SSS■:::5'!''::SS/..■■.■■■■■..■■■■■■■■■.■■■O■