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154 Brookdale Drive Lot 14 Section 2i DAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENTS PERMIT AND CERTIFICATE COMP E ION *NOTE: Issued in Compliance With Article II of G.S. Chapter 130a Sanitary Sewage Systems. _ Permit Number Name \� ,; 4> �, �� _ ri. Date J �� i NO', c; Location' Subdivision Name } _ �''Y y �� A��" Lot No. Sec. or Block No. Lot Size j '+ (IU House lrr Mobile Home _ Business -- Speculation No. Bedrooms LA No. Baths —� �Y No. in Family _ Garbage Disposal,, YES ❑ NO Eg/ Specifications for System: Auto Dish Washer YES NO ❑ ) �, ov "� (�� ?tib _ - ^ O Auto Wash Ma thine YES NO ❑ Type Water Supply ' �� .: �_� --- UU 'y Li , *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. 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 6 Date 41 -l� *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 Health Department Environmental Health Section P. O. Box 665 Mocksville, NC 27028 sted By I-- I.� .s Mailing Address n_ • C/, `// / ,,'4-, fry =r�4,/ - - , / UU ,h f Home Phone _,a r L ----2D L. -J= Business Phone 2. Name on Permit if Different than Above 3. Application/Permit for: ❑ General Evaluation ❑ Septic Tank Installation 4. System to Serve: [ House ❑ Mobile Home ❑ Place of Public Assembly ❑ Business ❑ Industry ❑ Other ❑ Unknown 5. If house, mobile home: Subdivision ' �� Section -2 Lot # No. of People No. of Bedrooms No. of Bathrooms Dwelling Dimensions L V 1 6. If business, industry, place of public assembly, other: Specify type No. of People Served No. of Commodes No. of Sinks 1-12— No. of Urinals No. of Lavatories s No. of Water Coolers No. of Showers Water Usage Figures ❑ Basement/Plumbing Basement/No Plumbing Washing Machine Dishwasher ❑ Garbage Disposal 7. Type of water supply: Public ❑ Private ❑ Community 8. Property Dimensions ,[� �%� Sewage Disposal Contractor /J, GAJ 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes A 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: �� () f SZ7 J This is to certify that the information provided is correct to the best of incurred from this ap licat' n. 4- 0 TE and I understand I am responsible for all charges 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. 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 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) APPLICATION FOR SITE EVALUATION/ IMPROVEMENTS PERMIT �< < Davie County Health Department Environmental Health Section jj�' Ir P. O. Box 665 Mocksville, N.C. 27028��' '0 CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT 1. Permit Req 2. Address — Home P� hone / y06 By X ; _ a69 0,J/, i✓� ,oo!!!Q Business Phone 3. Property Owner if Different than Above Address 4. Permit To: a) Install_At!!fAlter Repair Z3,n► b) Privy Conventional /-**" Other Type Ground Absorption c) Sub- Division ' e r � "Ad, )-/Itec Lot No. f� 5. System used to serve what type facility: House— Mobile Home Business IndustryOther b) Number of people 6. a7 If house or mobile home, state size of home and number of rooms. House Dimensions Bed Rooms_ Bath Rooms Den 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 3 urinals garbage disposal lavatory showers washing machine dishwasher sinks f2_4 8. a) Type water supply: Public. dD Private— Community b) Has the water supply system been approved? Yeses No 9. a) Property Dimensions Z' E b) Land area designated to building site c) Sewage Disposal Contractor r!'oYhr i�-2,�,e 10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve? What type? This is to certify that the information is correct to the bes�of my knowledge. Date Owner Signat re OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS Allow 5 days for processing Directions to property: DCHD (6-82) �+ DAVIE COUNTY HEALTH DEPARTMENT ' Environmental Health Section Soil/Site Evaluation NAME DATE EVALUATED ADDRESS PROPERTY SIZE QAC PROPOSED FACIILTY ,!��,i� LOCATION OF SITE Water Supply: On -Site Well Community Publicy Evaluation By: Auger Boring L/ Pit Cut FACTORS 1 2 3 4 Landscape position Slope Z HORIZON I DEPTH Texture group Consistence Structure MineralogX HORIZON I.I. DEPTH Texture group Consistence Structure 6 x S' l Mineralogy 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 L �f SITE CLASSIFICATION: l� EVALUATED BY: I (a l LONG-TERM ACCEPTANCE RATE: ` OTHER(S) PRESENT: REMARKS: // 11 / "?o %%� 5. /tll� / � (,, 1�-SsG 7 LEGEND Landscave 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 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 Mineraloey 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 watet 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 Davie County A(ealtf De artment ltli Aen and .7fome .mea y cy 210 HOSPITAL STREET / P.O. BOX 665 MOCKSVILLE. N.C. 27028 PHONE: (704) 634.5985 October 3, 1991 Linda Dillingham Box 829 Advance, KC 27006 Re: Site Evaluation Greenwood Lakes -Lot 14 Dear Ms. Dillingham: As requested, a representative from this office visited the aforementioned site on September 26, 1991. Only the front portion of the site was found provisionally suitable for the installation of a ground absorption sewage system. A pump may need to be used. If you have any questions, please feel free to contact this office. Sincerely, A�Z- WAWA Robert B. Hall, Jr., R.S. Environmental Health Section RH/wd Enclosure