280 Deadmon Road Lot 51-40
DAVIE COUNTY HEALTH DEPARTMENT
'� IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
•NOTE:lssued in Compliance With Article II of G.S. Chapter 130a
Aanitary ewage Systems Permit Number
NameDate=ZL' 1�f N2 7990
Location
Subdivision Name in, Lot No. Sec. or Block No.
Lot Size /Z X30_ House —lam Mobile Home —_— Business --_ Industry
No. Bedrooms ---.No. Baths No. in Family�Z� --_ Public Assembly Other
Garbage Disposal YES ❑. NO 211 Specifications for System:
Auto Dish Washer YES NO j,
Auto Wash Ma-hine YES NO ❑
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. intended use change
ATTENTION: YOUR SEPTIC SYSTEM CONTRACTOR MUST SEE THIS PERMITILAYOUT BEFORE INSTALLING THIS
SYSTEM.
Improvements permit by —Z/I �L_
*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: 704.634.5985,
Final Installation Diagram:
System Installed by
Certificate of Completion __ Date 1
`The signing of th s 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.
1. Application/Permit
Mailing Address
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section
P. O. Box 665
Mocksville, NC 27028
2. Name on Permit if Different than Above
3. Application for: ❑ General Evaluation Septic Tank Installation Permit
4. System to Serve: Er House
❑ Mobile Home ❑ Place of Public Assembly
❑ Business ❑ Industry ❑ Other ❑ Unknown
5. If house, mobile home: Subdivision � � 41-bor Section Lot #
No. of People
No. of Bedrooms
No. of Bathrooms 9—
Dwelling Dimensions /1(�
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
❑ P' t
❑ Basement/Plumbing
❑lBasement/No Plumbing
E(Washing Machine
21 Dishwasher
❑ Garbage Disposal
7. Type of water supply. Public riva a ❑Community
8. Property Dimensions A60 x -300 Sewage Disposal Contractor A. '411,
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:
This Is to certify that the information provided is correct to the
incurred from this 9pplicoon.
DATE
I am responsible for all charges
SIGNATURE
CONSENT FOR SITE EVALUATION TO BE DONE 9N 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.
DATE SIGNATURE
DCHD (1/97)
APPLICATION FOR SITE EVALUATIONAMPROVEMENTS PERMIT
1. Application/Permit Requested By
Mailing Address
Davie County Health Department
Environmental Health Section
P. O. Box 665
Mocksvllle, NC 27028
2: Name on Permit If Different than Above
3. Application for:
4. System to Serve:
RECE11 ED
NOV 2 81994
---------------
Business Phone %D -351 7-222—
Evaluation ❑ Septic Tank Installation Permit
❑ Mobile Home ❑ Place of Public Assembly
❑ Business ❑ Industry I El Other ❑ Unknown
5. If house, mobile home: Subdivision SOU`w. =tnr)(.L Section S Lot # S
❑ Basement/Plumbing
22
No. of People J/Z ❑Base ent/No Plumbing
No, of Bedrooms t77-3ashing Machine
No, of Bathrooms Dishwasher
Dwelling Dimensions AAMAr• ❑ Garbage Disposal
6. If business, industry, place of public assembly, other: Specify type
No. of People Served 1444 No. of Sinks
No. of Commodes 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 Sewage Disposal Contractor
9. Do you anticipate additions/expanslon 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,
This is to certify that the Information provided is correct to the best of
incurred from thisis�app%�'caatioo
AT
I am responsible for all charges
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 j AM 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.
DATE SIGNATURE
DCMD (IID3)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section ^ ,�
Soil/Site Evaluation
NAME T ��(� 2 w 1 e Q G Oct DATE EVALUATED ` I- 71
ADDRESS S'A TD -R PROPERTY SIZE
PROPOSED FACIILTYy J G LOCATION OF SITE
Water Supply: On -Site Well Community Public
Evaluation By: Auger Boring - Pit 'V - Cut
FACTORS
1
2 3 4
Landscape position
T
11
Slope Z
p_ o
d_ go
HORIZON I DEPTH
fa 211
(e-121`
Texture group1.
Consistence
'L
7
Structure
Mineralogy
t
HORIZON II DEPTH
Texture grou
Consistence
C'L
Structure
Mineralogy
HORIZON III DEPTH .
Texture group
Consistence
Structure
Mineralogy
HORIZON IVDEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
S S
S
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE
Lk
SITE CLASSIFICATION: •S•
LONG-TERM ACCEPTANCE RATE: y
REMARKS:
DCHD(01-901
EVALUATED BY: Q:" 2_t) JVl5t
OTHER(S) PRESENT:
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
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
Saprolile - 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(suilable), PS(provisionally suitable), U(unsuitable)
LTAR - Long-term acceptance rate - gal/day/ft2