177 Foster Road Lot 55? DAVIE COUNTY HEALTH DEPARTMENT
' IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTE: Issued in Compliance With Article II of G.S. Chapter 130a
Sanitary Se age Syssttems/J ; f'Tj,q�//. Permit Number
Name GGl/'/I/!�i /�J!(SGt�// Date �oZ NO 68Ov
Location ..l�J�/✓/: �� ii� �o/� .i��i �/ .�/ O T^r c�� i �i/
Subdivision Name '),WZ" ``/f
Lot No.
Lot SizeHouse Mobile Home _✓ Business __ Speculation
No. Bedrooms ,No. Baths — No. in Family _
Garbage Disposal YES ❑ NO �`
❑ L'J Specifications for System:
Auto Dish Washer YES NO
Auto Wash Ma^hine YES ❑ NO �5 Addr �y
VAS I�
Type Water Supply
C1,4 4
*This permit Void if sewage system described below is not installed withiri'5 years from date of issue.
This permit is subject to revocation if site plans or the intended use change.
I==
P -
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
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.
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L x4el ixeleLrJ f✓
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APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT`
Davie County Health Department 1�'(�''EIVED
Environmental Health Section
P. O. Box JUL
2 t 1991
2 G
j(}4C Mocksville, NC 27028
1. Application/Permit Requested By J,911q
P P P
Mailing Address 1Z nX )3 7,
��e V
L �4,
Home Phone `JoY 8 -2 e:> 9 3 if
Business Phone
%i F%? 30-00
2. Name on Permit if Different than Above
3. Application/Permit for:
❑ General Evaluation
2 -Septic Tank Installation
4. System to Serve: ❑ House
C9 -Mobile Home
❑ Place of Public Assembly
❑ Business ❑ Indust
❑ Other
El Unknown
S. If house, obiie home: ubdivision �A
ction Lot #
❑.Basement/Plumbing
No. of People ,
ElBasement/No Plumbing
No. of Bedrooms Z
C l
❑ Washing Machine
No. of Bathrooms
❑ Dishwasher
Dwelling Dimensions
❑ Garbage Disposal
6 If business industrYlace of public assemblyother: Specify type
• ,
No. of People Served
No. of Commodes
No. of Sinks _
No. of Urinals
No. of Lavatories No. of Water Coolers
No. of Showers Water Usage Figures
7. Type of water supply: M Public�Pppp�I�g" ElPrivate ❑ Community
8. Property Dimensions / Zo X i.30 14 • Sewage Disposal Contractor
9. Do you anticipate additions/expansion of the facility this sytem is intended' toy serve? 9�s ❑ No
If yes, what type? 1 �� U. L-�-- ZTiZ t � ` ,4-ts, —
`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_
5e- 2D
I - z Ul e-6 (a+ -h'-- s o -r /elf
4LS
& /4 Ipej
�—o Fa40�1 1�
This is to certify that the information provided is corr¢ct thhe best of�g�y knowledge, and I understand I am responsible for all charges
incurred from this application. 1 O I/ I
SIGNATURE
CONSENT FOR SITE EVALUATION 1Q BE DONE ON ABOVE DESCRIBED PROPERTY
MUST CHECK ONE: I 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
DCHD (1290)
SIGNATURE
^ DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation a%
NAME �DATE EVALUATEDJ�d
ADDRESS PROPERTY SIZE �7;f6
PROPOSED FACIILTY LOCATION OF SITE % XC l
Water Supply: On -Site Well / Community Public
Evaluation By: - AugerBoring_Pit Cut
FACTORS 1
2 3
4
Landscape position
(�
L
Slope %I
HORIZON I DEPTH •t
7
e,
Texture group
PC r
PL
Consistence
Structure
Mineralogy
HORIZON II DEPTH /$
«
Texture group
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
,
SITE CLASSIFICATION:
r
LONG-TERM ACCEPTANCE RATE:
REMARKS:
Landscave Position
EVALUATED BY: A,;_4 Y.
OTHER(S) PRESENT:
LEGEND
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
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/ftz
DCHD (01-901