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a% A
DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
`NOTE:'Issued in Compliance With Article 11 of G.S. Chapter 130a
Sanitary Sewage Systems/ Permit Number
Name A ;���� T: „ ��i%V%i' N�� c
Location —
r-
Subdivision Name ' "'� /�`«�"�rl ,��''�r` �� Lot No. Sec. or Block No. I
Lot Size ��t' House � Mobile Home _ Business __ Speculation
No. Bedrooms - No. Baths �' No. in Family
Garbage Disposal YES ❑ NO D-' Specifications for System:
Auto Dish Washer YES NO ❑ "Iel' �,, "�! /
Auto Wash Ma^hine YES i _ NO ❑
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.
f
Improvements permit byT
'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.
i i s —7t -
Final Installation Diagram:
System Installed by
Certificate of Completion f` 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
i Davie County Health Department •
Environmental Health Section �9••
c P. 0. Box 665
Mockaville, NC 27028
1. Application/Permit Requested By
Mailing Address T (F l JY(l X 1b o �.t,� �, i nIA-
Home Phone `� � Business Phone
loo
2. Name on Permit if Different than Above
3. Property Owner if Different than Above .4 ,-
4. Application/Permit For: 0 General Evaluation S/Tank Installation
S. System to Serve: m House 0 Mobile Home 0 Business
Industry Other 0 Unknown
6. If house, mobile home: Subdivision Im_AArf�r4 J';�-" Sec. Lot#
No. of People Dwelling Dimensions�ikS�
No. of Bedrooms Basement/Plumbing
No. of Bathrooms Basement/No Plumbing
0 Washing Machine0 Dishwasher 0 Garbage Disposai
7. If business, industry, other: Specify type
No. of People Served
No. of Commodes
No. of Lavatories
No. of Showers
No. of Sinks
No. of Urinals
No. of Water Coolers
8. Type of water supply: Public 0 Private 0 Community
9. Property Dimensions I , � QA)ch4<)
10. Sewage Disposal Contractor
11. Do you anticipate additions/expansions of the facility this system is
intended to serve? 0 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.
This is to certify that the information provided is correct to tree
best of my knowledge, and I understand I am responsible for all
charges incurred from this application.
5 ql. -, rup
Date Si nature
Directions to Property:
DCHD (10-89)
f
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
NAME��ve._ DATE EVALUATED
ADDRESS
PROPOSED FACIILTY
PROPERTY SIZE Me -
LOCATION OF SITE el le 'Y✓,r c'
Water Supply: On -Site Well Community Public Cm.�
Evaluation By: Auger Boring Pit Cut
FACTORS
I 1
2
3
4
Landscape position
.e.
Slope %
HORIZON I DEPTH
Texture group
Consistence
Structure
6" -
Mineralogy
HORIZON II DEPTH
1/D
d
1511-11
Texture group
ell,
ell,C
Consistence
Structure
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
,f
SITE CLASSIFICATION: & EVALUATED BY:
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 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