910 Mr Henry Road Lot 8e
DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE•OF COMPLETION
*NOTE: Issued in Compliance With Article II of G.S. Chapter 130a
Sanitaryy�Seewage S 3 ems Permit Numbed
Name \.." �v` \o°•.nv� i_Pat 5
Ng 7186 0
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Subdivision Name
Lot
No. Sec. or Block
No.
Lot Size House— Mobile Home Business __
Speculation
No. Bedrooms
:No. Baths No. In Family
_
✓
Garbage Disposal
YES ❑ NO
p SPegLiitions
for Syestem
Auto Dish Washer
YES NO
Auto Wash Ma:hine
YES p NO ❑: r.
pCl
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 intendd use change.
� n
Improvements permit by --
'Contact a representative of the Da a County r+Department for final inspection of this system between 8:30-
9:30 A.M. or 100-1:30 P.M. on d y of co E i 1Te1le'phone Number 704-634-5985.
1
Final Installation Diagram: System Installed by
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r
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e
Certificate of Completion _ Date �- 1 ` C3
'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 betaken as a guarantee that the system will function
satisfactorily for anv given Deriod of time.
aE kEQVED
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department MAY 2 01993
Environmental Health Section
P. O. Box 665
Mocksville, NC 27028
1. Application/Permit Requested By12
Mailing Address�p'
Home Phone R�p ' �a ( Business Phone
2. Name on Permit if Different than Above
3. Application/Permit for: ❑ General Evaluation �. Septic Tank Installation
4. System to Serve: ❑ House [ Mobile Home ❑ Place of Public Assembly
❑ Business ❑ Industry p /❑ Otheerr- ❑ Unknown
5. If house, mobile home: Subdivision �✓- ` I V`Q/L r �� Section Lot #
❑ Basement/Plumbing
No. of People nnJ ❑ Basement/No Plumbing
No. of Bedrooms -,E:r Washing Machine
r,
No. of Bathrooms !< �� ❑ Dishwasher
Dwelling Dimensions1 0�1 X L,7=)' ❑ Garbage Disposal
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
7. Type of water supply: ❑ Public '0 Private
8. Property Dimensions Sn (l 0 Y'eS Sewage Disposal Contractor
9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes
If yes, what type?
M.
❑ 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:
iceVltaeod-eh-\-\ o MQ•1 n�'i 1`>�d. - �a5 Rc�I-(eel5e��-
Lc - and
`?5,,,J e .
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 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
DCHD (1290)
a DAVIE COUNTY HEALTH DEPARTMENT
y Environmental Health Section
Soil/Site Evaluation
NAME ohs DATE EVALUATED
ADDRESS PROPERTY SIZE
PROPOSED FACIILTY LOCATION OF SITE
a�l�w
Water Supply: On -Site Well Community - Public
Evaluation By:OfL Auger Boring ✓ Pit Cut_
FACTORS
1
2
3
4
Landscape position
f
5
S
Slope Z
Q' t
Fr' 13
0- l5°
iS i g'o
HORIZON I DEPTH
Texture groupC
C L
1
Consistence
$
Structure
Z
MineralogyI
•t,
't
HORIZON II DEPTH
93
Lit"
Texture group
C_
C -
Consistence
Y'
Structure
Mineralogy:1
:t
HORIZON III DEPTH
Texturerou
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
S
-S
RESTRICTIVE HORIZON
-
-
-
SAPROLITE
-
-
-
CLASSIFICATION
S
LONG-TERM ACCEPTANCE RATE
SITE CLASSIFICATION:' S EVALUATED BY:
LONG-TERM ACCEP�•
TANCE RATE: S OTHER(S) PRESENT:
REMARKS: �io�.\Ay earl - �ax.� s� a��•
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 -Sands clay SIC -Silty clay C -Clay
CONSISTENCE
Moist
.VFR-Very friable FR -Friable FI -Finn 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