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829 Gladstone Road Lot 9DAVIE COUNTY HEALTH ;�- IMPROVEMENTS PERMIT AND CERT *NOTE: Issued incompliance With Article II of G.S. Chapter 130a Sanitary Sewage Systems DEPARTMENT FICATE OF COMPLETION Date v ^ o Permit -Number N° 8118 Subdivision Name > it i N1 r J, / l Lot No. Y Sec. or Block No. Lot Size ��JC--- House — L Mobile Home ---_ Business --_ Industry No. Bedrooms � L _.No. Baths —,2-- No. in Family — Public Assembly Other Garbage Disposal YES ❑ NO p-- Specifications for System: Auto Dish Washer YES NO 4 ❑ �DD���// l Auto Wash Ma^hine YES W NO ❑ r. Type Water Supply — --------- 110 r3X/� *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 ATTENTION: YOUR SEPTIC SYSTEM CONTRACTOR MUST SEE THIS PERMIT/LAYOUT BEFORE INSTALLING THIS SYSTEM. t 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., 1:00.1:30 P.M. or 4:30.5:00 P.M. on day of completion. Telephone Number: 704.634.5986YOO Final Installation Diagram: 60' Ta UA1A IN A, i y Certificate of Completion z` Date /l7 _–�-�-�-- '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. V"I�V 7' 1. Application/Permit Mailing Address_ APPLICATION FOR SITE EVALUATIONAMPROVEMENTS PERMIT Davie County Health Department Environmental Health Section P. O. Box 665 Mocksville, NC 27028 Business Phone 6=52m 2. Name on Permit if Different than Above 3. Application for: ❑ General Evaluation ❑ Septic Tank Installation Permit 4. System to Serve: House ❑ Mobile Home ❑ Place of Public Assembly ❑ Business ❑ Industry ❑ �Otthher .// ❑ Unknown 5. If house, mobile home: Subdivision S�AelrJd�i��➢S Section Lot # 9 ❑ Basement/Plumbing No. of People ❑ Basement/No Plumbing ,No. of Bedrooms ❑ Washing Machine No. of Bathrooms ❑ Dishwasher. Dwelling Dimensions ❑ Garbage Disposal 6. If business, industry, place of public assembly, other: Specify type No. of People Served No. of Sinks No. of Commodes 9 No. of Urinals No. of Lavatories No. of Water Coolers No. of Showers Water Usage Figures 7. Type of water supply: Public ❑ Private ❑ Community 8. Property Dimensions / f%iLC Sewage Disposal Contractor 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes ❑ 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: A'(©�SS This is to certify that the information provided is correct to the best incurred from this applic ----/ DATE and I understand I am responsible for all charges 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. SIGNATURE DCHDlUM iA DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation NAME I� ��ir�77� DATE EVALUATEDo7e2� ADDRESS PROPERTY SIZE PROPOSED FACIILTY LOCATION OF SITE Water Supply: Evaluation By: On -Site Well Auger Boring - Community - - Pit_Ll___� Public 4__� - Cut FACTORS 1 2 3 4 Landscape position Slope R HORIZON I DEPTH Texture groupL Consistence Structure Mineralogy HORIZON II DEPTH a L Texture group Consistence i Structure Mineralogy i 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: OS EVALUATED BY: Al LONG-TERM ACCEPTANCE RATE: OTHERS) 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 Moist- VFR-Very friable FR -Friable FI -Firm VFI-Very firm EFI-Extremely firm We[' - - 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