295 Bridle Lane Lot 5y-- DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTE: Issued in Compliance With Article 11 of G.S. Chapter 130a
SanitpaSewage Syste s\ Permit Number
Name tc6��s c� �" t I Date ^�' N2 7 7 3 4
Location Ll —I
}� �a'C ��J r���^ t• '��, �.� .
Subdivision Name -Lot..-. Sec. or Block No.
Lot Size i., House~ Mobile Home — Business -- Industry
No. Bedrooms No. Baths — No. in Family_— Public "Assembly Other
Garbage Disposal YES ❑ NO (t/ Specifications for System:
Auto Dish Washer YES NO ❑ f ,��� ,,;.� C�4 - \ '�
Auto Wash Ma^hine YES NO ❑ 0011
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 by
*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 cdtlnplekn. Telephone Number: 704-634-5985.
Final Installation Diagram:
F System Installed by
co
F
Certificate of Completion %J --Date 1 - 9 5�
*The signing of this certificate shall indicate that the system describe 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.
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APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section--11E
P. O. Box 665��
Mocksville, NC 27028 Std 2
1. Application/Permit Requested By
Mailing Addre
Home Phone
-------------...r
o
Business Phone ��J�
2. Name on Permit if Different than Above Yl� AA C-
3. Application/Permit for: General Evaluation ❑ Septic Tank Installation
4. System to Serve: JW House ❑ Mobile Home ❑ Place of Public Assembly
❑ Business ❑ Industry ❑ Other ❑ Unknown
5. If house, mobile home: Subdivision ko bk, Fc r /h Section A114 Lot #
. J Basement/Plumbing
No. of People ❑ Basement/No Plumbing
No. of Bedrooms __ -3 Washing Machine
No. of Bathrooms D— - 01 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
No. of Sinks
No. of Urinals
No. of Water Coolers
Water Usage Figures
7. Type of water supply: ❑ Public A4 Private
8. Property Dimensions SocRpS 0a6% X 8 7 J Sewage Disposal Contractor
9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes dr 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: avt of Rk 3a I f;/m me,'61,,-/ L% CORNOI Z"
eT bsJ �i�°r e24od aFT, AcParviGl Rd O^fef7'
P/egsE ca �/
IA/AOA) firi( J o,
a wo l�/od
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 th)s appl ation.
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&"14 / 9 Z — ; �/, W � �1-
DATE SIGNATURE
O� NSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY
MUST CHECK ONE: ❑ 1. 1 OWN the property. A 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 gavis County Health Department to enter upon above described
property located In Davie County and owned by N 2 . h /Q 6-157 C l Z� I_..
to conduct all testing procedures as necessary to determine said site's suitability for a ground absorption sewage treatment
and disposal system.
(Y -/7-I-/
DATE
DCHD (12.90)
DAVIE COUNTY HEALTH DEPARTMENT
• Environmental Health Section
Soil/Site Evaluation t�
NAME t�I +'� cC� �- DATE EVALUATED " 2 - 9
ADDRESS PROPERTY SIZE J �v�n
PROPOSED FACULTY 'A LOCATION OF SITE
Water Supply: On -Site Well V Community Public
Evaluation By�_"�l-- Auger Boring '� Pit Cut
FACTORS
1
2
3
4
Landscape position
S
-5
S
—S
Slope 9.
O- �D
�' �a
�' "
0- 1co
HORIZON I DEPTH
IF
Texture group
Consistence
-FT-
Structure
C V
Mineralogy
' 1
HORIZON II DEPTH
3�t'
�`•
S' `,'
Texture groupC
Consistence
Z
Structure
Q
ti3
Mineralogy
HORIZON III DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON--
SAPROLITE
CLASSIFICATION
�S
LONG-TERM ACCEPTANCE RATE
EKE
SITE CLASSIFICATION: .�� EVALUATED BY:
LANG-TERACCEP ANCE RATE: _ OTHER(S) PRESENT:
REMARKS: r 1 +
LEGEND
Landscave 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
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(01-90)