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231 Bridle Lane Lot 31-�5U DAVIE COUNTY HEALTH DEPARTMENT fb o b a IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION NOTE Issued in Compliance With Article I I of G.S. Chapter 130a Sanitary Sewage Systems Permit Number Name �� n _ Date dN2 7 6 8 0 Location tD Subdivision Name V �� Lot No. Sec. or Block No. f ` Lot Size Jr o_s�c House Mobile Home _ Business —_ Industry No. Bedrooms ' �2 —.No. Baths �� — No. in Family ? — Public Assembly Other Garbage Disposal YES g NO ❑ Specifications for System: Auto Dish Washer YES.(/ NO ❑ Auto Wash Ma-hine YES NO EJ 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. Improvements permit byQ *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 71 Wil Wm a )4 Q v-3-21 Certificate of Completion C. Date b - (�� —"T�ning 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. ' s DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation t' NAME `MAS' Sam �\ DATE EVALUATED ADDRESS �� `C�a PROPERTY SIZE PROPOSED FACIILTY a s 9 LOCATION OF SITE Water Supply: On -Site Well V Community Evaluation By:t'�-L Auger Boring l/ Pit Public Cut FACTORS 1 2 3 4 Landscape position S S -S Slope 7, CEF7 HORIZON I DEPTH /2 Texture group L C t_ L L Consistence -Z , X_ Z Structure C` Mineralogy HORIZON II DEPTH 6" 3 6 V —76-7--iTo Texture groupC e Consistence Structure 3 Mineralogy1'. i ► . I : i HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS _Ss S5 s s s s RESTRICTIVE HORIZON — - - - SAPROLITE CLASSIFICATION S S C LONG-TERM ACCEPTANCE RATE `t SITE CLASSIFICATION: �X '-�> EVALUATED BY: LONG-TERM ACCEPTANCE RATE: 1 OTHER(S) PRESENT: REMARKS: 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 -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 Mineralolty 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 ■E■ENNOMME■ ■■M■■E■E■E■ ■MEM■E■■■E■ ■■■MM■■■■E■ ■■■E■EME■O■ ■■EN■EME■E■ ■■■M■M■■■M■ J 1 . 1 APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT Davie County Health Department Environmental Health Section /bo P. O.. Box 665 ; (:�J Mocksville, NC 27028 ------------- 1. 1. Application/Permit Requested By Mailing Address S7 ivej Home Phone 2. Name on Permit if Different than Above -:) �6 0 1.0 3. Application/Permit for: ❑ General Evaluation M Septic Tank Installation 4. System to Serve: House ❑ Mobile Home ❑ Place of Public Assembly ❑ Business ❑ Industry / / ❑ Other ❑ Unknown 5. If house, mobile home: Subdivision ��,� &Arm Section 7_ Lot # —� ❑ Basement/Plumbing No. of People ❑ Basement/No Plumbing No. of Bedrooms C"Washing Machine No. of Bathrooms /� E!(Dishwasher Dwelling Dimensions lE"Garbage Disposal 6. If business, industry, place of public assembly, other: Specify type No. of People Served No. of Sinks No. of Commodes No. of Lavatories No. of Urinals No. of Water Coolers No. of Showers Water Usage Figures 7. Type of water supply: ❑ Public CKPrivate 8. Property Dimensions Sewage Disposal Contractor 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes If yes, what type? DINo ❑ 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: e r /e1 �- 41v #�- This is to certify that the information provided is correct to the best of incurred from this application. 7-,-� 7- ZV DATE knowledge, and I understand I am responsible for all charges SIGNATURE CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY MUST CHECK ONE: ❑ 1. 1 OWN the property. EK2' I 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 unty, Health Department to enter upon above described property located in Davie County and owned by D to conduct all testing procedures as necessary to determine sai site's suitability fora grgund absorption sewage treatment and disposal system. p DATE SIGNATURE DCHD (12-90) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation p NAME DATE EVALUATED - I v ADDRESS \ \ PROPERTY SIZE PROPOSED FACIILTY LOCATION OF SITE�� Water Supply: On -Site Well Community Public Evaluation By!Z,'�U— Auger Boring Pit Cut FACTORS 1 2 3 4 Landscape position .5 Slope HORIZON I DEPTH ! Texture group Consistence Y - Structure C" Mineralogy1 t HORIZON II DEPTH L)L, ' Ll ` )--1 G " [-1 Texture groupC L Consistence Structure `3 v MineralogyI . l HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS SS SS SS RESTRICTIVE HORIZON -- — -- SAPROLITE — — CLASSIFICATION LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: -� EVALUATED BY: LONG-TERM ACCEPTANCE RATE: l -� OTHER(S) PRESENT: REMARKS: 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 Moist VFR-V--ry 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 3C -Single grain M -Massive CR -Crumb GR -Granular ABK-Angular blocky SBK-Subangular blocky PL -Platy PR -Prismatic Mi neraloey 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 ■OMM■ ■■om■