111 Oakland Avenue Lot 62'DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION.
'NOTE: Issued in Compliance With Article I I of G.S. Chapter 130a �� +''� � • .,
Sanita ewag Systems /f �a r �''' 4(� { Permit Number
Name" / �; e Date
Location =�� _
Subdivision Name -� '`I '''Lot No. Se
' ' c.' or Block No.
��` Mobile H
1 Y
' Lot Size �&_& - — .House' ome —
_ —Business _— Industry
1.
No. Bedrooms . No. Baths. No. in Family' _ Public. Assembly Other
0.1
Garbage Disposal YES p NO [ " • `I
Specifications for System: ,
Auto Dish Washer YES p' NO 2 � c, % t-�Voo,X' ,-s� `
Auto Wash Ma^hine YES Q''�NO..Q /- (' --'Gc Xf✓�
Type Water Supply"_ .f r t,kj 5
:—
'This'permit'Void if sewage system described below isnot installed within 5 years from date ofissue.
This permit is subject to reVocation, ff site plans or the intended use change
ATTENTION: YOUR SEPTIC SYSTEM CONTRACTOR MUST SEE THIS PERMIT/LAYOUT BEFORE INSTALLING THIS
SYSTEM. i
fi.
44, 11
Improvements permit by
'Contact a representative of the Davie;County'Heajth.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: 704-634-598b.g'�(p '
Final Installation Diagram j System Installed by.G�O
. Certificate of.Completion _Date ��� 9
'Thesigning 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 betaken as a guarantee that the system will function
satisfactorily for any given period of time:. fi
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
�a
Davie County Health Department
Jb t Environmental Health Section
j /l �a P. O. Box 665
11►C� Mocksville, NC 27028
1. A lication/Permit Requested B l'1 i201'j5 i"�✓� "may y `�` < ' "f�� a�
'� Y
g 14 Gum qto X E-n(a
Mailing Address � Home Phone
0 -5 t)i lle, /y C ; �
//''%6 `Zk Business Phone 916 72,7— & b 49
to
2. Name on Permit if Different than Above R" i *-L �2 Ca
3. Application for: General Evaluation a Septic Tank Installation Permit
4. System to Serve: Z House ❑ Mobile Home ❑ Place of Public Assembly
❑ Business ❑ Industry �J ❑ Other ❑ Unknown
5. If house, mobile home: Subdivision %a ",/y S Section Lot # AK�l�
❑ Basement/Plumbing
No. of People ❑ Basement/No Plumbing
No. of Bedrooms 5:22� 22 P�L Washing Machine
No. of Bathrooms % ❑ 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
7. Type of water supply: L" Public
No. of Sinks
No. of Urinals
No. of Water Coolers
Water Usage Figures
❑ Private
8. Property Dimensions y�lfC� Sewage Disposal Contractor
9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes ❑ 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:
.r1
This is to certify that the information provided is correct to th
incurred from this p li tion.
DATE
stof y 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. ❑ 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
If
disposal system.
DATE SIGNATURE
DCHD (193)
DAVIE COUNTY HEALTH DEPARTMENT
• Environmental Health Section
Soil/Site Evaluation
NAME
ADDRESS
PROPOSED FACIILTY
Water Supply: On -Site Well
oakTzi
DATE EVALUATED
PROPERTY SIZE
LOCATION OF SITE
Community
Public ✓
Evaluation By: Auger Boring I/ Pit Cut
FACTORS
1
2
3
4
Landscape position
L
L
L
Sloe %
2
Z
HORIZON I DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH
Texture group
Consistence
i
Structure
.5-b'e'
Mineralogy
HORIZON III DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
SIT
7-7
LONG—TERM ACCEPTANCE RATE
Ir/
,
SITE CLASSIFICATION: /:� EVALUATED BY:
LONG-TERM ACCEPTANCE RATE: 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 ;lay loam, SIL -Silty loam CL -Clay loam SCL-Sandy clay loam
SC -Sandy clay SIC -Silty clay C -Clay
CONSISTENCE
Moist
VFR- V ----y 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
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)
Daae County NealtFi Department
and Nome Neallir Ayency
210 HOSPITAL STREET/P.O. BOX 665
MOCKSVILLE. N.C. 27028
PHONE: (704) 634.5985
March 13, 1995
Habitat for Humanity
c/o Diane Crotts
164 Gumberry Lane
Mocksville, NC 27028
Re: Site Evaluation
Oakland Heights/Sec. 1 -Lot 62
Dear Ms. Crotts:
As requested, a representative from this office visited the aforementioned
site on March 9, 1995. Based upon the information provided on the application
for site evaluation and after the evaluation was completed, the site was found
to be provisionally suitable for the installation of an on-site sewage disposal
system.
If you have any questions, please feel free to contact this office.
Sincerely,
Robert B. Hall, Jr., R.S.
Environmental Health Section
RH/wd
Enclosure.