411 Madison Road Lot 12CO-T--.,.z:;c..: !"'vlVry.:Yati�;v 5-""i�g - _ .. - vr�.. .c.�.. ..rc n,_.:-•�•'a'�2v-qr ...;:
r 'tn_ DAVIE COUNTY HEALTH DEPARTMENT )v
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION,
*NOTE: Issued in Compliance With Article 11 of G.S. Chapter 130a
to mew e e § Permit Number
il�7o,�<�g ��x:��io�/a./� s -ice 93 I
Name Date— NO 7172
s/,14;re., p' 1461 k1.4 .r��rn>,/�l -
�cNy iG'O
Subdivision Name Lot No. Sec. or Block No.
Lot SizeHouse Mobile Home —T Business Speculation
No. Bedrooms No. Baths No. in Family
Garbage Disposal
YES ❑
NO ❑
Auto Dish Washer
YES ❑
NO ❑
Auto Wash Ma:hine
YES ❑
NO ❑
Type Water Supply
S it Ptii fo�ystem:
'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.
0
4
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:
9
w;
System Installed by
u
F–
. / 14 6 tjs- I.
r
ne
aC's
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 anv civen Deriod of time.
Y°<
'"
=a
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 anv civen Deriod of time.
APPLICATION FOR SITE EVALUATIONflMPRO'
Davie County Health Department
Environmental Health Section
P. O. Box 665
Mocksville, NC 27028
1. Application/Permit Requested By
Mailing Address
Home Phone
2. Name on Permit if Different than Above
CO aSTRUCTION CO., INC.
NC
Business Phone
2=1
DAVIE COUNTY HEALi H DEPT.
3. Application/Permit for: ❑ General Evaluation ❑ Septic Tank Installation
4. System to Serve: [House ❑ Mobile Home ❑ Place of Public Assembly
❑ Business ❑ Industry ` ❑ Other ❑ Unknown
5. If house, mobile home: Subdivision s,b>Z°a ? WBP Section Lot #
No. of People
No. of Bedrooms
No, of Bathrooms �, /
Dwelling Dimensions y
6. If business, industry, place of public assembly, other: Specify type
No. of People Served
No. of Commodes
No. of Lavatories
No. of Sinks
No. of Urinals
No. of Water Coolers
tasement/No
ement/Plumbing
Plumbing
1/ ashing Machine
/ishwasher
❑ Garbage Disposal
No. of Showers Water Usage Figures
7. Type of water supply Pujblic V � ❑Private ❑ Community
8. Property Dimensions Sewage Disposal Contractor
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:
L�1i
i
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 frgm thr � plicate ^ ��
DATE \-9IW9rbRE
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 (12-80)
�s DAVIE COUNTY HEALTH DEPARTMENT.
Environmental Health Section
S it S•t E al ation '
Q o/ 1 e
NAME �I DATE EVALUATED
ADDRESS PROPERTY SI2'E /DDd�Da
PROPOSED FACIII.TY
LOCATION OF SITE Jb A -JZ .LIV !
Water Supply:
Evaluation By:
On -Site Well
Auger Boring
'Community
Pit
Public
Cut - -
Landscape position
4L
FACTORS
1 2
3
4
Landscape position
4L
Sloe Z
G
HORIZON I DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH
-" 6l -
Texture groupG
Consistence
it
Structure
Mineralogy
HORIZON III DEPTH
Texture groupJ
Consistence
/
Structure
Mineralogy
HORIZON I,V,.Dm
Tame group
Consistence
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE
SITE CLASSIFICATION: Cb EVALUATED BY: A� 4/Z
LONG-TERM ACCEPTANCE RATE: 7 OTHER(S) PRESENT:
REMARKS:
LEGEND
- - 'Landscape Position -
R -Ridge S -Shoulder L -Linear slope FS -Foot slope N-Noseslope`
-- -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 -Film 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