127 Ada Lane Lot 20DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
•NOTE: Issued in Compliance With Article II o,W.S. Chapter 1 Oa
sanit ryse�agesy@tams I d/n Orno> Permit
Number
Name o b W �, 5 c, e� -QI Dat ( 1 - NO 1 0 41
Location to V6 o� j LZ `} e X
15 `=. `�, ccs �'s��,`�• �'�, - ��1s� �a' `.7... 1JTurr?. - �1 >s�'
Subdivision Name Lot No. Sec. or Block No.
>`
Lot Size y r �, V jf 9 House V
No. Bedrooms No. Baths
Garbage Disposal YES ❑ NO
Auto Dish Washer ' YES 'NO ❑
Auto Wash Ma shine . YES NO _LD
Type Water Supply C " L1_"7
— Mobile Home�— Business —_ Speculation
No. in Family _
Sp,ecilicat ons�for�System- \� a`.,
- - n
'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.
10 0'
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: Systell Installed by W� T
Y
D�
I
i
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.
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT `II
Davie County Health Department
Environmental Health Section; 8
P. O. Box 665
Mocksville, NC 27028
1. Application/Permit Requested By
Ot ri—
Mailing Address 0d Z6.ka 7f E.rl&49 ail A/C-
Home Phone��7e s — 7SiY—S Si 9 Business Phone
2. Name on Permit if Different than Above
3. Application/Permit for: ❑ General Evaluation k Septic Tank Installation
4. System to Serve: House ❑ Mobile Home ❑ Place of Public Assembly
❑ Business ❑ Industry ❑,Other ❑ Unknown
5. If house, mobile home: Subdivision Section Lot #
❑ Basement/Plumbing
No. of People ❑ Basement/No Plumbing
No. of Bedrooms ;tT Washing Machine
No. of Bathrooms .d _ .9 Dishwasher
Dwelling Dimensions ❑ 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
7. Type of water supply: Its Public
8. Property Dimensions
No. of Sinks
No. of Urinals
No. of Water Coolers
Water Usage Figures
❑ Private
Sewage Disposal Contractor
9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes ❑ No
If yes, what type?
❑ 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:
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.
bra /
DATE SIGNATURE
CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY
MUST CHECK ONE: ❑ 1. 1 OWN the property. J�r 2. 1 DO NOT OWN the property.
If you checked Box #2, the rest of this formIvM SST 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 Se 6Er XP ^� -
to conduct all testing procedures as necessary to determine said site's suitability for a ground absorption sewage treatment
and disposal system.
H , 847 A04 1124
��� DATE SIGNATURE
DCHD (12-90)
V
"E1 a 8 111 Pn 153
r>V ,: * M 06;O!
1
S CORNER'
75�,Sf. ONTROL COR�e --
�,- 36. C ZO'
r 7 ) 4 I
,��{. � � /���•-I-.• ;;� -79� 3'-44 -r-
Ci t 0.604 AC. `:� v �4oi
78 �s
7j 17 N W
-: 16� W _ _ N-60 TOT4
C WILL!
i--2286_ ----� ,W 0.841 Al. 86• GB
✓� i. v dvrlutr EASEMENT 'r; v ,,, 9S 42 39"E
tr) 3 • @ 35897 TOTAL
P w `` n' n N 4 t :tc. a 179.
^! p�GO 2 �N ; Z �� a CCM7ROL CCRNER f 27.18 152.56 175.00
, S 86.42' 39'E
0' 670 AC , o so\a- 0-730 A o ,� u, r 175.00
z zzs.ea C c c 0.795 AC. 5 c 0. -807 Al.�'r 17s.Cp i
160-00 z J t c O 7 e O
614.95 TOTAL— 175.00 `00 r., �° 1 6 06 o 8 = 0
53 ri �,'e3 3
ap N 86' 17' ;6• W 7.�4U 2✓C c - t c;o �� - p W r. o•-
i;(PUELI SThEET) <:j q '�41� Z / O
. ! GIINNY LANE pry 0 8 Gc� 0.804 Al.
I G J c6° 17 5 c 5(722TOT_'
uS :✓;V 95,� 2 s 0 -COS C. i �-
/j 707 ��U C c)Iss
a r.
-<�. ����.,� =E'' GIfJNY LA "L�E'`2' \.
r N _ _ _
t13 31 _ L =� r �'` j'= �Py C c C
132.<7 -_'. c iC'AL
(3247 t70—
Cc :O�: .i: r •7fT- 18.62 Qu I !_'1
J/r l
561 c. � �v • _ N CO'1 S
16 A 14
.23 c0� C. Y'^ -, m— rry
13
0 I! O �•
n r:
MO . n N n 2<8.�9 O t7 186. a+N �- . O ? 0 937 AC. 05 z
O ci O O -`'` 89 0-901Ac.z I-012 Ac. 0-„_2 AC.
?inn 0.'768AC. o - _- ,. 0.561 Al. :, 0.914 Al.fi ,i = z ''
21 O - - -
1
'� 8S• - �• .-►8-0_---"-13253---�\H alE .-- 1-_-...-�- --
-S- -
BS
---
uTlurr jp• EASEMENT (1 51.58
t3_'56"W EaSErEMT -DE-SL 0 •54"w
3O.Is 1210
N 86.02' 25� N 8 7.55' 5� L--115.07--- 60-94 _E . p0 54,.w 10 IITILI, 10 UTiLEti FASEYENT
150.56 TOTAL 49046 TOTAL S SS NEAL S. GORDON
` ECA
PLAT 9K.4 PG. 11
M na•�s'., 12tORG�57IV 4k.
`1
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
NAME
ADDRESS S P rc Q
PROPOSED FACULTY Hoo SCP
Water Supply: On -Site Well
Evaluation Byj.r-*r.L Auger Boring
./
DATE EVALUATED - - f 3
PROPERTY SIZE
LOCATION OF SITE
Community Public 1✓
Pit Cut
FACTORS
1
2
3
1 4
Landscape position
So
1
-S
Slope 9.
5
HORIZON I DEPTH
Texture group
L
C 1--
C L
C L_
ConsistenceZ
Structure
Q
z
R
C R
Mineralogy
..1
►
1: 1
V.
HORIZON II DEPTH
XA1`
a
Texture group
C
C
r
Consistence
-
Structure
V
Q
b
Mineralogy
.,
t
` 1
\
HORIZON III DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
g 5
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
pig
LONG-TERM ACCEPTANCE RATE
rLr
1 ,1
y
SITE CLASSIFICATION: \'�e' -'.
LONG-TERM ACCEPTANCE RATE:
REMARKS: '
DCxD (01-90)
EVALUATED BY: C'_.'�
ATA We%DVncnQ . K1_\t�V
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-Firon 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)
Soii 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
DAVIE COUNTY HEALTH DEPARTMENT ZD
Environmental Health Section
R O. Box 665
Mocksville, N.C. 27028
y� SOIL/SITE EVALUATION
Name G.StJ1�+-} 6�' �w Date
Address Lot Size
FAr.TnP.Q
AREA 1 APPA 9 AREA R ARFA A
Topography/ Landscape Position
SS
S
S
PS
PS
PS
U
U
U
U
!) Soil Texture (12-36 in.) Sandy,S
PS
S
S
Loamy, Clayey, (note 2:1 Clay)
PS
PS
PS
U
U
U
U
i) Soil Structure (12-36 in.)
<ns>
S
S
S
Clayey Soils
PS
PS
PS
PS
U
U
U
U
1) Soil Depth (inches)
<::�>
S
S
S
PS
PS
PS
PS
U
U
U
U
i) Soil Drainage: Internal
S
S
S
PS
PS
PS
PS
U
U
U
U
External
S
S
S
PS
PS
PS
PS
U
U
U
U
i) Restrictive Horizons
Available Space
S
S
S
S
PS
PS
PS
�
U
U
U
i) Other (Specify)
S
S
S
S
PS
PS
PS
PS
U
U
U
U
)) Site Classification
U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable
-------------
Recommendations/Comments:
Described by • " " un Title
SITE DIAGRAM
DCHD (6-82)
Date e,"Z'bY