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204 Merry Lane Lot 10 Davie County Health Department q his Environmental Health Section e P.O. Box 848 L 210 Hospital Street �� O 'S Courier# : 09-40-06 Mocksville, NC 27028 Phone:(336)-753-6780 Fax:(336)-751-8786 ON-SITE WASTEWATER CERTIFICATION FOR DWELLING (Check One) Replacement Remodeling Reconnection r ' 33 Name: Nl f t akcL (A X00 l_ Phone-, m(M � q O Home) Mailing Address: oy MQ r,ry Ula g l8 Sy�" y��� (Work) 1'fPJl l�Olna i A!( g-70OG Email �y c Detailed Directions To Site: 5 �r /t O r Property Address: Please Fill In The Following Information.About The EXISTING Facility: Name System Installed Under: &l T ej /�O �i�/G � Type Of Facility: Date System Installed(Month/Date/Year): 'l 2 Number Of Bedrooms: Number Of People: Is The Facility Currently Vacant? Yes If Yes,For How Long? Any.Known Problems? Yes Too If Yes,Explain: Please Fill In The Following Information About The NEW Facility: Type Of Facility: Wt I ou C4 Od L 'k 3O Number Of Bedrooms: Number of People Requested By: 'tee[late Requested: —�� - (Signature)- J For Environmental Health Office Use Only Zm)ents: Disapproved Environmental Health Specialist Date: 2© *The signing of this form by the Environmental Health 13 ff 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: as Check Money Order # Amount:$ (0.C}(D Date: Paid By: 1 h orn fi-S PR-/fit e- �(S��Q�� Received By: Account#: Invoice#: ��rj� d a � ••---..r.�.r•��•--s••..:Vr�c.•Srjw�-.-rowfi"y..A.v=�-"ti,t-'v"3-d3q'..�i/t%r7�iS..i,"'�1K.�''J-��` ..�.�iS.r .-� .' ,. :s- •�7"�••'.- O. r DAVIE COUNTY HEALTH DEPARTMENT f� 06 IMPROVEMENTS PERMIT AND .CERTIFICATE Ok COMPLETION *NOTE:Issued in Compliance With Article 11 of G.S.Chapter 130a .Sanitikry Sewage Systems Permit Number Name 2*tel !R 11 6d)4astir._ Date -11 - y 11 N0. aas6 - 65.75 Location MOMN • r L1 F— Subdivision Name Lot No. Sec. or Block No. Lot Size -House; Mobile Home _T Business Speculation No. Bedrooms: .No. Baths '. No:sjn Family j Garbage Disposal . YES p 'NO Specifications for System: Auto Dish Washer. YES 21�op NO p �v Auto Wash Ma thine YES NO p J t Type Water � Supply ,:•c., _ X *This permit Void if sewsae system a elow is not installed within 5 years from date of issue. This permi is ubject to re– v-oca"tlarri4-si ns intended use change. j IUD { �, lip ► - n . Improvements permit by��. � .9.. C. ..4 *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 O 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 theabove regulation, but shall in NO way be taken as a guarantee that the system will function satisfactorily for any given period of time. • D.,AVIE COUNTY HEALTH DEPARTMENT -� IMPROVEMENTS PERMIT AND .CERTIFICATE OF COMPLETION *NOTE:Issued in Compliance With Article 11 of G.S.Chapter 130a Sanit ry Sewage SystemsPermit Number t 0 Name bA2- Date � 1 ' `` ' N Location — _, Subdivision Name + 4' Lot No. _J(J Sec. or Block No. Lot Size House L' Mobile Home __�_____ Business Speculation No. Bedrooms No. Baths No.In Family Garbage Disposal YES ❑ NO (]-r Specifications for System: Auto Dish Washer YES [E]'! NO E3 -Tax, Auto Wash Ma thine YES p' NO ❑ Type Water Supply 3 0, 0 ' *This permit Void if sewage system to d scri•b- elow is not installed within 5 years from date of issue. This permit is ubject to revo'`�"ca-ti6-n-if-sRe ^nsbol, a intended use change. 4 wr ';gip lt,ui t ii q 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. r Final Installation Diagram: System Installed by s� e'—/ f -peak F t� usIL � 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 Ap,_To -// Davie County Health Department Environmental Health Section P. 0. Box 665 Mocksville, N.C. 27028 CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED. 1 Home Phone 1. Permit Requested By � _u)a� ­ l A e� f\,�c�� Business Phone 2. Address ('6\e-t` ('u kf�m'3e . rc�P�'C'siEc"Ov1e- Qc nc— a?oyk 3. Property Owner if Different than Above 7; m n_J� S, Address PFp, 3c_ , � O-o b 4. Permit To: a) Install Alter Repair b) Privy Conventional Other Type Ground Absorption c) Sub-Division Sec. Lot No. 5. System used to serve what type facility: House v'-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 Bed Rooms Z Bath Rooms w/Closet b) If Business, Industry or Other, State: Number of persons served What type business, etc. Estimate amount of waste daily (24 hours) 7. Number and type of water-using fixtures: commodes a urinals garbage disposal lavatory showers a 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 72 C d\ �S b) Land area designated to building site c) Sewage Disposal Contractor 10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve? Al 0 What type? This is to certify that the information is correct to the best of my knowledge. & A apt- S4 Date Owner Signature OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS Allow 5 days for processing Directions to property: nn Ps Jr o See 0 d , 0 i\ 1 0 C'\ S IA' 1_4e,�e, � � 1 ' DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation NAME �" �`� �s��- DATE EVALUATED ' - 9 ADDRESS SPX" PROPERTY SIZE f' PROPOSED FACIILTY LOCATION OF SITE _c) Water Supply: On-Site Well Community Public Evaluation By: C1_ Auger Boring Pit Cut FACTORS 1 2 3 4 Landscape position � S Sloe Z O r C_, n -?° C) -8" HORIZON I DEPTH b" it !t " Texture group S t S �- Consistence Structure Mineralogy HORIZON II DEPTH nR: 1 Texture rou ('Consistence Structure ra ��Mineralo 1; I; j HORIZON III DEPTH Texture grou2 Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON — SAPROLITE - CLASSIFICATION LONG-TERM ACCEPTANCE RATE tq C , '-/ , L/ SITE CLASSIFICATION: J EVALUATED BY: C LONG-TERM ACCEPTANCE RATE: LI- 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 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 ■■■.■■..■■.■■■■■■■..■■..■.■..■■.■....■■■■■.■■......■■.■.■.■■..■■■■ ........................... .....■................................ .................................................................. ■■■..■■■■.■■■■■■■■■....■■■.■.....■ ■■■..■.■■...■...■.■■.■■■■■■■■■■ ■■■.■■■.....■■■.■..■.■.....■..■■..■.......■..■■■■■■..■■■■■■..■ ■■■ ■■■■■■■H■■■■■eJ■■■■..■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■.■.■■■■....�■■■ ■iiiiiiiiui®iiiiiiiiiiiiiiiiiiiii.■iii■iiiii■■iiiiiiii■iii■iiiiiiii .....■........■.........■.■....■......................... ..■■■■■■ ::::u: :::::: :::::: ::::::MEMME:: :::::: MENNEN ■■......■i,.il■■■■iZ7...■.■i i:::iiM===:tiw■....... ..■.....■■■■�■■■■ ■■■■.■■..sir■i�.■■■■■■.■■■r�■■■■...■.■..■.■p...■■.■■�■■■■■■■■.■.. ...■ ■■.......ne■■.■■■■■.■■■.■i■.�c■ ■�►_�■■■.■■a.■■... ■■■■■■u■■ ■.mom■ ■ ........................��........■......■�......�.■_ ■■■..■■C■■■■■■�■ ■.■■■■.■■■■.■.■■....■■■■��■■■n�■■■.■■■■.■a■■u■.■■■ ■■■■■■.■■■■■■.■■ iiiiiiiiiiiiiiiiiiiiiiiiuiiiuu�i'�ii�iiiiiiiiiiii■�INS M MMIMME■iiiii= ■.....■■■.■..■■■■.■■■■■■i�.■■.■..�■.■■■in...■■.0 ■■■■■■■■.■■■■■■■■ iiiiiii iii�iiiiiiiii iiiiiiiiii■■�iiriii ................................ ....... ........................ .................................................................. .................................................................. .................................................................. .................................................................. .................................................................. ■■■■■■■■■■■■■■■■■■■■■■■■■■.■■■■H■■■■■■i■■■.....■■...■■......■■■■■ ����tt■A�tttW.t/ttttttt� � All data is provided as is without warranty or guarantee of any kind either expressed or Implied Including but not limited to the Implied warranties of merchantability or fitness for a particular use. All users of Davie County's GIS website shall hold harmless the County of Davie, North Carolina, its agents, consultants, contractors or employees from any and all claims or causes of action due to or arising out of 1 the use or Inability to use the GIS data provided by this website. G � T Printed:Apr 30, 2013 e e fit. rN Gu I 0..04 V