169 Foster Road Lot 4DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT ANDCERTIFICATE OF COMPLETION
•NOTE: Issued in Compliance With Article II of G.S. Chapter 130a
�Sanitary Sew ge System l' / Permit Number
Name /ro�11//y rDC�Gr%00�/T7 0? �u.Date �� �` 9Py NO 7217
17
le
Location VPS-G� �d /D �%P .�� %> ��—�i✓— t
Subdivision Name �De 7 Lot No. Sec. or Block No. '
,r�UW
Lot Size House Mobile Home _ y Business — Speculation2^ ,
No. Bedrooms No. Baths No. in Family V —
Garbage Disposal YES ❑ NO ['J Specifications f System:) wGt
Auto Dish Washer YES ❑ NO /OOl owe.
Auto Wash Ma:hine YES NO ❑
Type Water Supply_—
*This permit Void if sewage system described below is.n t installed within 5 years from date of issue.
This permit is subject to revocation if site plans r t in nded use change.
Improvements permit by —_I/�` /
"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: ste In tailed by
Certificate of Completion
Date 27
r`
*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.
�, N",9 i. �. ,�„..�. �, n•^yr. ..j,,: -w....,_.. ., _._ .�`-'.�'•:c..-`-�' _t -V I:- �,�v AV "1
DAVIE COUNTY HEALTH DEPARTMENT
d
-,IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTE: Isqued in Compliance With Article it of G.S. Chapter 130a
SantaSe7�age Systems Permit Number
'yij//JIJi 6/Gl;.luicc-moi �'TrY�A/�.? �%i/ �,C,?��9P �'° �Jc�3�.
Name Date —
(ocation
�)7
Subdivision Name "S Lot No. 7 Sec. or Block No,
Lot Size 160 House Mobile Home Business Speculation
No. Bedrooms No. Baths No. in Family
Garbage Disposal YES ❑ NO [l Spe
Auto Dish Washer YES n' NO E]
Auto Wash Machine YES' NO ❑ � X��x/� � �J
Type Water Supply /T __—
*This permit Void if sewage system described
This. permit is subject to revocation if site pla
installed within 5 years from date of issue.
nded use change. i
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 cpmpletion. Telephone NuTber 704-634-5985.
Final Installation Diagram:
f, Y4D r
i.
k
Iled by
60
I �A
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 anv oiven neriod of time.
J
*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 cpmpletion. Telephone NuTber 704-634-5985.
Final Installation Diagram:
f, Y4D r
i.
k
Iled by
60
I �A
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 anv oiven neriod of time.
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERr,' IE OW
r Davie County Health Department
Environmental Health Section L Q
P. O. Box 665 JUN 1 8 19
✓v�Mocksville, NC 27028
1. Application/Permit ested.By '� /L /
Mailing Ad-.---
(1128 Home Phon�o Business Phone 7,5r_T1 �9
2. Name on Permit if Different than Above
3. Application/Permit for: ❑ General Evaluation
4. System to Serve: ❑ HouseMobile Home ❑
Septic Tank Installation
of Public Assembly
❑ Business ❑ Industry • / /� ❑ Other ❑ Unknown
5. If house, mobile home: Subdivision ��/�L /A(//t(/)J Section Lot #
No. of People
No. of Bedrooms 3
No. of Bathrooms
Dwelling Dimensions x
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: �(PublicEl Private
8. Property Dimensions 700 1100. Sewage Disposal Contractor
9. Do you anticipate additio s/expansion of the f ility t is yte i intended to serve? / J iYes
If yes, what type? �����). �% ��� N 6 ' 5-l�
❑ Basement/Plumbing
❑ Basement/No Plumbing
Washing Machine
❑ Dishwasher
❑ Garbage Disposal
❑ 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: /(��� 2� FO $fi�Y /2 4 �n
This is to certify that the information p wded is
T red from thi JlicetioynS
DATE //
best of
lam
CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY
MUST CHECK ONE: Al. I OWN the property. . ❑ 2. 1 DO NOT OWN the property.
If you checked Box #2, the rest of this f m UST be mpl ed by the owner or a person authorized by the owner:
I hereby give consent to the authorized rep se tali o t iemy h artme to enter upon above described
property located in Davie County and o ed by
to conduct all testing procedures as n cessary to r in aid si sui bility fora d absortkion sewage treat nt
andisposaI system.
DATE SIGNATURIE
for all charges
,l
`<
DAVIE COUNTY HEALTH DEPARTMENT
! Environmental Health Section
j Soil/Site Evaluation / J
NAME DATE EVALUATED
ADDRESS l / PROPERTY SIZE S��G
PROPOSED FACIILTY /%l I!V LOCATION OF SITE
Water Supply:
On -Site Well
Community
Public
Evaluation By: -
AugerBoring
Pit -
- Cut -.
FACTORS
1
2
3
4
Landscape position
L
C
�-
Slope %
HORIZON.I DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH�O
"
91'
Texture groupG
Consistence
I
;
Structure
JY1
Mineralogy
HORIZON III DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group r'
Consistence
Structure
Mineralogy
SOIL WETNESS .
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
S
7
S
LONG-TERM ACCEPTANCE RATE
.
,
SITE CLASSIFICATION: - !/7 d.�✓ �p �c - -
LONG-TERM ACCEPTANCE RATE: a
REMARKS:
DCHD (01-901
EVALUATED BY: �/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 -Nonplastic 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