902 Mr Henry Road Lot 70(0
K_ DAVIE COUNTY HEALTH DEPARTMENT
'T IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTE: Issued in Compliance With Article II of G.S. Chapter 130a
–Sanitary Sewage Systems /GT'rur;a a Ja,. Permit Number
Name / d>:/ Date —Z��C ! 5 N2 8121
Location\At"'(eTr
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Subdivision Name 407 A' A zge A/Cegir Lot No. �_ Sec. or Block No.
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Lot Size �>��— House —� Mobile Home —4L — Business --_ Industry
No. Bedrooms __,E _.No. Baths —_P_— No. in Family S Public Assembly Other
,
Garbage Disposal YES ❑ NO p''
Specifications for System; ✓_S�D
u&A4. (%a„�
Auto Dish Washer YES NO ❑ /p9QQ 6 �I r
Auto Wash Ma^hine YES (j NO ❑ ,/
Type Vater Supply — �;rir ;� ----- -- C �f%G' X �C 2
*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.
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Is permit by —�91
*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. of 4:30-5:00 P.M. on day of completion. Telephone Number: 704.634-f3M.$760
Final Installation Diagram: System Installed by
a
F
Certificate of Completion _L__`x'LDate
'The signing of this certificate shall indicate that the system described above has been installed in compliance with
the standards set forth in the above regulation, but shall in NO way be taken as a guarantee that the system will function
satisfactorily for any given period of time.
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APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT ` , p o
Davie County Health Department V/ �Nh
Environmental Health Section
P. O. Box 665
Mocksville, NC 27028
1. Application/Permit Requested By
(<
Mailing Address /h Sf ('� a r h� rct 1�n • Home Phone �15-- 27/t>
)'Y)OGKSU i lLE 0• L• a74-)- Business Phone
2. Name on Permit if Different than Above
3. Application for: ❑ General Evaluation Septic Tank Installation Permit
4. System to Serve: f House �f$ Mobile Home ❑ Place of Public Assembly
a
❑ Business ❑ Industry ❑ Other ❑ Unknown
5. If house, mobile home: Subdivision vAe ��+ /� /LP,' /. elm_r Section Lot # 4W I
No. of People
No. of Bedrooms V )P:44 y I�
No. of Bathrooms a
Dwelling Dimensions
6. If business, industry, place of public assembly, 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
Water Usage Figures
❑ Basement/Plumbing
❑ Basement/No Plumbing
Washing Machine
f t Dishwasher
❑ Garbage Disposal
7. Type of water supply: ❑ Public X Private ❑ Community
8. Property Dimensions .1 picy-e C, Sewage Disposal Contractor M i'he r ++ons
9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes ;K 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:4c)�iYl le ,S 40 5G-5GA'c
6o I d -v � I: sbr rY KcSt -�< , �1 � 6�� A r a
n � f s c� -10 40
+A-�1v� �'
l�of n vk4 10 tt
This is to certify that the information provided is correct to the best of my knowledge, and I understand I am responsible for all charges
incurred from this application.
DATE 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 MUS 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 syste
DATE
WHO (tt93)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section _
Soil/Site Evaluation
NAME_ �xli/'e—
ADDRESS
PROPOSED FACIILTY
Water Supply: On -Site Well
Evaluation By: AugerBoring ✓"
DATE EVALUATED S`AVAYS_
PROPERTY SIZE �tiy/C
LOCATION OF SITE fes'/7P/rTG/ '
Community
P: r .
- Public �-
Cut
FACTORS
1
2
3
4
Landscape position-.
L
.
4
.-
Slope R
CiJ
HORIZON I DEPTH
Texture group
rez-
Consistence
-
Structure
Mineralogy
HORIZON II DEPTH
Texture group
Consistence
Structure
7,�
/
/J
Mineralogy
HORIZON III DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON.
SAPROLITE
CLASSIFICATION
S
LONG-TERM ACCEPTANCE RATE
,'
SITE CLASSIFICATION: �� /✓lOP ip •'
LONG-TERM ACCEPTANCE RATE:
REMARKS: moi% IM�
EVALUATEDBY:
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 <:lay loam, - SIL -Silty loam CL -Clay loam SCL-Sandy clay loam -
SC -Sandy clay SIC -Silty clay C -Clay -
., rnacreTnvna _ -
Moist -
VFR,Vc.ry friable FR -Friable FI -Firm VFI-Very firm EFI-Extremely firm .
Wet
NS -Non sticky SS -Slightly sticky S -Sticky VS-VerySticky
.. NP -Non plastic SP -Slightly plastic P -Plastic .VP -Very plastic
Structure
3C -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(01-90)
Dan? County YfealtFrDepartment
and Nome Nealtl Ayency
210 HOSPITAL STREET/ P.O. BOX 665
I .
MOCXSVILLE. N.C. 27028
PHONE: (704) 634-5985 -
May 17, 1995
Mary McIntyre
168 Barbara Lane
Mocksville, HC 27028
J
Re: Site Evaluation
Mr. Henry Road/5.1 Acres
Dear Mr. McIntyre(
As requested, a representative from this office visited the aforementioned
site on May 12, 1995. Based upon the information provided on the application
for a site evaluation and after the evaluation vas completed, the site vas
found to be provisionally suitable for the installation of a modified,
oversized on-site sevage disposal system.
If you have any questions, please feel free to contact this office.
Sincerely,
j p
Robert B. Hall, Jr., R.S.
Environmental Health Section
RH/wd
Enclosure