129 Parker Rd Lot 4_ 'r'1. i`Y+r .S r'S 1r':"1 i EP;. vpi yllrG: 'rt..✓r —z r,' .:>� * '�;..�t I f, -p.y •�.� .ho -,F. �,r-ia. ,` S:. .�.. .� t•r #1'"
DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTE: Issued in Compliance With Article II of G.S. Chapter 130a
Sanitary Sewage Systems Permit Number
Name r�rT 1,1%frh s"l7/�J %l /j� . %� Date /. ` �/ N2 69,04
Location U� �l%" /j� f" �i.�: ; .9��r ,!c� cit ✓ 0`%
Subdivision Name Lot No. Sec. or Block No.
Lot Size / House Mobile Home —_ Business Speculation
No. Bedrooms ` X4 No. Baths No. in Family 2-_17
YES Disposal —
Garbage Dis NO
g p ❑ � Specifications for System:
Auto Dish Washer YES ❑ NO Z'
Auto Wash Machine YES e NO ❑ �/ V ,�/� �,
Type Water Supply A4
*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
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
1-7
I- �
�J
Certificate of Completion / v� Date i 7
'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.
w
Z
r ,
1. Application/Perry
Mailing Address
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section
P. 0. Box 665
Mocksville, NC 27028
Home PhoneBusiness Phone 3 q� �T
2. Name on Permit if Different than Above
3. Application/Permit for: ❑ General Evaluation � Septic Tank Installation
4. System to Serve: I House ❑ Mobile Home ❑ Place of Public Assembly
❑ Business ❑ Industry ❑ Other ❑ Unknown
5. If house, mobile home: Subdivision Section Lot #
6. If business, industry, place of public assembly, other: Specify type
No. of People Served
No. of Commodes
No. of Lavatories
No. of Sinks
No. of Urinals
No. of Water Coolers
No. of Showers Water Usage Figures _
7. Type of water supply: Public ❑ Private
8. Property Dimensions �_OL4 QA- Sewage Disposal Contractor
9. Do you anticipate additionstexpansion of the facility this sytem is intended to serve?
If yes, what type?
❑ Yes X No
❑ Community
'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: - a/YIA)— eaAAfCt
PO
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 SIGNATURE
CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY
MUST CHECK ONE: ❑ 1. 1 OWN the property. W 2. 1 DO NOT OWN the property.
If you checked Box #2, the rest of this form MUST be completed by the owner or a person authorized by the owner:
I hereby give consent to the authorized representative of the Davie County Health Department to enter upon above described
property located in Davie County and owned by —/-)i o ALt 5 mcCrr P
to conduct all testing procedures as necessary to determine said site's suitability for a ground absorption sewage treatment
and disposal system.
DATE SIGNATURE
DCHD (12.90)
❑ Basement/Plumbing
No. of People Jy
❑ Basement/No Plumbing
No. of Bedrooms
VWashing Machine
No. of Bathrooms 0
❑ Dishwasher
Dwelling Dimensions
❑ Garbage Disposal
6. If business, industry, place of public assembly, other: Specify type
No. of People Served
No. of Commodes
No. of Lavatories
No. of Sinks
No. of Urinals
No. of Water Coolers
No. of Showers Water Usage Figures _
7. Type of water supply: Public ❑ Private
8. Property Dimensions �_OL4 QA- Sewage Disposal Contractor
9. Do you anticipate additionstexpansion of the facility this sytem is intended to serve?
If yes, what type?
❑ Yes X No
❑ Community
'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: - a/YIA)— eaAAfCt
PO
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 SIGNATURE
CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY
MUST CHECK ONE: ❑ 1. 1 OWN the property. W 2. 1 DO NOT OWN the property.
If you checked Box #2, the rest of this form MUST be completed by the owner or a person authorized by the owner:
I hereby give consent to the authorized representative of the Davie County Health Department to enter upon above described
property located in Davie County and owned by —/-)i o ALt 5 mcCrr P
to conduct all testing procedures as necessary to determine said site's suitability for a ground absorption sewage treatment
and disposal system.
DATE SIGNATURE
DCHD (12.90)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
NAME /� ��(� DATE EVALUATED
ADDRESS
PROPOSED FACIILTY
PROPERTY SIZE
LOCATION OF SITE �'f1/`✓' ��
Water Supply:
On -Site Well
Community
Public
Evaluation By:
Auger Boring t1-11,
Pit
Cut
FACTORS
1
2
3
4
Landscape position
Sloe %—
HORIZON I DEPTH
(�
IV,''
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH
Texture groupC
C
Consistence
Structure
Mineralogy
/, V
I/•_7'
HORIZON III DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE
5/
SITE CLASSIFICATION:
LONG-TERM ACCEPTANCE RATE:
REMARKS:
DCHD(01-901
EVALUATED BY: /YLZ /Z
OTHER(S) PRESENT:
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
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DAVIT COUFTY HEALTH DEPARTiIEFT La
ENVIR01111EBTAL HEALTH SECTION
SOIL/SITE, EVALUATIO11
11AME -b_hy %4Ntclers DATE
ADDRESS 315" Sa.i1s�-s '.
LOCATION S,e. /Jo1 /foS--
La f 0,
LOT SIZE /DD ',YZ 0o
TOPOGRAPHY: 5
l2 -f X
SOIL TEI,TURE : Ps
SOIL STRUCTURE:�Pj
DEPTH: S
RESTRICTIVE HORIZONS: 41414--f— ,,,1,, S��R./'� , ` "e7llef a /S -Z"
PERCOLATION RATE:
1.
2.
3.
Presoak
Hark & time
Drop Time
Pate Iiin. Inch
W, Ot2S'
1114
to;Ss
to O: 2'r
a
0:.�5-
too
**"'CLASSIF'ICATIOII:Suitable Provisionally Suitable Unsuitable
COMMEITTS :
SAPIITARIA17 �, Pk"
�
SITE DIAGFI
PERCOLATION PATEt
1.
2.'
3 . -
Presoa
''Hark& time
Drop Time
Rate/Nin. Inch`.
16" o:2r
iy�
�osS�
24-.
'
CLA5IF'ICATIOt? s
Suit'eule
Provisionally Suftabl~e��'`� Unsuitable
COtSMITS
'
SANITARIAI] iMOi^^
SITE .DIAGRAM
�Z
'D