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353 Bridlle Lane Lot 8P�_,✓)e0 DAVIE -COUNTY HEALTH DEPARTMENT 0 IMPROVEMENTS PERMIT AND CERTIFICATE, OF COMPLETION. 'NOTE: lastiedfin Compliance With Article II of G.S. Chapter 130a ✓3 �j%(,e 3° oO Sanitary Sewage Systems Permit Number Namee �� �-�``_� `� Date(_ NO 79.73 Location �.,,�lo ,� 4}.a� `�. 0c'� ante rj 1Ji�. 0 ��tl � �._—. V,t.:a� ��3:iw-�'+ �?wl'i �Si.�. �1�� Q'A •'�.ka..C�..'+"` T Subdivision Name Lot No. g Sec: or Block No. Lot Sized House —� Mobile Home — Business —_ Industry N0. Bedrooms ' .No. Baths —�* ?_ No: in Family ! PubllcAssembly Other Garbage Disposal YES P( NO p Specifications for System: Auto Dish Washer YES [ NO Auto Wash Ma^hine YES NO Type Water Supply _ " 3 aSQ j u .y '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 PERMIT/LAYOUT BEFORE INSTALLING THIS SYSTEM., -? Improvements permit by *Contact a representative of the Davie County Yealth 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 co pletion. Telephone Number: 704-634-5985. Final Installation Diagram. System Installed by w1R� Hs� . r t• ry r Certificate of Completion �� __ Date f 'The signing of this certificate shall indicate that the system described above has beer' 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. r r ' APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT Davie County Health Department Environmental Health Section P. O. Box 665 Mocksville, NC 27028 1. Application/Permit Requested By Mailing Address `� tn" vy�'oh Z , _ I Cl \ –.1— Business Phone 2. Name on Permit if Different than Above 3. Application for: ❑ General Evaluation 4. System to Serve: House ❑ Business ❑ Industry 5. If house, mobile home: Subdivision USeptic Tank Installation Permit ❑ Mobile Home ❑ Place of Public Assembly ❑ Other ❑ Unknown Section Lot # ❑ Basement/Plumbing ❑ Basement/No Plumbing as ' g Machine ishwasher arbage Disposal 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 No. of Showers Water Usage Figures 7. Type of water supply: ❑ Public 0&-�) rivate ❑ Community 8. Property Dimensions 3 O O X F "1 / Sewage Disposal Contractor 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 rrect to the best of my knowledge, incurredfrom �application. ,`.1ocl ` S DATE I -- I am responsible for all charges CONSENT FOR SITE EVALUATI TO BE DONE ON ABOVE DESCRIBED PROPERTY MUST CHECK ONE: Pl. I 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 representativ of the Dayli County Health epa ent to enter u on a ve described property located in Davie County and owned t r c to conduct all testing procedures as necessary to det inek said site's suitability for a_ground absorption sewage treatnieni and disposal system. ATE SIGNATURE DCHD (1/93) ,mer ? No. of People \ No. of Bedrooms 3 No. of Bathrooms Dwelling Dimensions N g USeptic Tank Installation Permit ❑ Mobile Home ❑ Place of Public Assembly ❑ Other ❑ Unknown Section Lot # ❑ Basement/Plumbing ❑ Basement/No Plumbing as ' g Machine ishwasher arbage Disposal 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 No. of Showers Water Usage Figures 7. Type of water supply: ❑ Public 0&-�) rivate ❑ Community 8. Property Dimensions 3 O O X F "1 / Sewage Disposal Contractor 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 rrect to the best of my knowledge, incurredfrom �application. ,`.1ocl ` S DATE I -- I am responsible for all charges CONSENT FOR SITE EVALUATI TO BE DONE ON ABOVE DESCRIBED PROPERTY MUST CHECK ONE: Pl. I 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 representativ of the Dayli County Health epa ent to enter u on a ve described property located in Davie County and owned t r c to conduct all testing procedures as necessary to det inek said site's suitability for a_ground absorption sewage treatnieni and disposal system. ATE SIGNATURE DCHD (1/93) ,mer APPLICATION FOR SITE EVALUATIOWIMPROVEMENTS PERMIT p Davie County Health Department Environmental Health Section P. 0. Box 665 Mocksville, NC 27028 1. Application/Permit Requested By LSA, TX e,- /N e -- Mailing Address 26 L F914w5 �� Home Phone L Business Phone 2. Name on Permit if Different than Above -5-,4m e-- 3. Application/Permit for: ❑ General Evaluation 2 'Septic Tank Installation 4. System to Serve: EllHouse ❑ Mobile Home ❑ Place of Public Assembly ❑ Business ❑ Industry ❑ Other ❑ Unknown 5. If house, mobile home: Subdivision No. of People No. of Bedrooms No. of Bathrooms 12� Dwelling Dimensions S�g 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 Section tot # ❑ Basement/Plumbing [I Basement/No Plumbing 2 -Washing Machine 0 -Dishwasher 9 -Garbage Disposal No. of Showers Water Usage Figures 7. Type of water supply: ❑ Public C�PrivateC]Community 8. Property Dimensions / re S Sewage Disposal Contractor �� e /�l i b 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: n11C �e-,�4 OWk-4 --1.r,� . r Oj r ram ©J— 0<4fv�5 % Nell e— . seo TA, 4. -e- 5 5 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. DATE SIGNATURE CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY MUST CHECK ONE: ❑ 1. 1 OWN the property. B-2. 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 Daa�v�*e C unty Health Department to enter upon above described property located in Davie County and owned by �JQ4 ry , " s e'at to conduct all testing procedures as necessary to determine said site's suitability for a ground absorption sewage treatment and disposal system. DATE SIG URE l DCHD (12.90) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation NAME _ �� S rte, DATE EVALUATED 93 ADDRESS PROPERTY SIZES \ PROPOSED FACIILTY LOCATION OF SITE y.,�`�• c� Water Supply: On -Site Well Community Public Evaluation By:�. Auger Boring l/ Pit Cut FACTORS 1 2 3 4 Landscape position Sloe Z n- - p - —Q:) - -- HORIZON I DEPTH ' 6 Texture group L S S C Consistence Structure Mineralogy'1 HORIZON II DEPTH qnat 1' " 1' r+ Texture grou L_ C L Consistence Structure 'a B Mineralogy HORIZON III DEPTH Texture RE022 Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS Ss 1r RESTRICTIVE HORIZON-- SAPROLITE — — — CLASSIFICATION LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: '` ' S EVALUATED BY: LONG-TERM �CCEP�TANCE RATE: T OTHER(S) PRESENT: _4 REMARKS: EGEND 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 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 watef 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)