316 Oakland Avenue Lot 114'�': ',., �R `t` - -. ..-� r..�..- i�.-.,p� mow.. �:ri•i�L�"..,a.--�Y-�, rru-a�.q�;�;-c
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DAVIE COUNTY HEALTH DEPARTMENT
Y�
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION J
* NOTE: Issued in Compliance With Article 11 of G.S. Chapter 130a
rntary Sewage ystems Permit Number
NamDate N
,� o 1128
e
Loca ion
Subdiyisior?,Norpe • - Lot No. Sec. or Block No.
Lot Size - House'. Mobile Home _ Business _ Speculation
=::.�No.
No. Bedrooms .No. Baths in Family �-
Garbage Disposal YES ❑ NO ❑
SPi�ications for yst
Auto Dish Washer YES ❑ NO
Auto Wash Ma^.hine YES NO ❑ _ rn CJ;'
Type Water Supply
*This permit Void if sewage system dd b w is not installed within 5 years from date of issue.
This permit is subject to revocation if ite pla or a intended use change.
lo/
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. or 1:00-1:30 P.M. on day of completion. Telephone Number 704-634-598\5.
Final Installation Diagram: System Installed by e b o
.y
1 ,
r �
t
Certificate of Completions Date S ra 4
*The signing 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
s satisfactorily for any given period of time.
IAV g�
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APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT' -
Davie County Health Department
Environmental Health Section
P. O. Box 665
r,
Mocksville, NC 27028 81993
ell
1. Application/Permit Requested By. \J ►tee C—O nib
Mailing Address F
Home Phone (0�) o - 2? / i Business Phone
2. Name on Permit if Different than Above AIM
3. Application/Permit for: 2 General Evaluation ❑ Septic Tank Installation
4. System to Serve: ❑ House 2� Mobile Home ❑ Place of Public Assembly
❑ Business ❑ Industry ❑ Other ❑ Unknown
5. If house, mobile home: Subdivision0C�%n c� �'c -4 f .S Section Lot #
No. of People
No. of Bedrooms 2
No. of Bathrooms
Dwelling Dimensions
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 ❑ Private
8. Property Dimensions Inn I X 1'216;X 110'x 125"
Sewage Disposal Contractor
❑ Basement/Plumbing
❑ Basement/No Plumbing
"ashing Machine
❑ Dishwasher
❑ Garbage Disposal
9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes VNO
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.
(6+(14i
Directions to Property: (,J� �rom MQLksu,Ke_ +o C_ctr+Ata^s ri C, l,Oj u. y e + R o r �f—
a0 ,�.,y �akla•,� Avg, Dew, 4- f- k; 1 I
61 c c ""',C) a cam- C,,t, up W.11
13w`► 1'o+ S 1�1gr i<e d 1 14 -'-'kms r"•��:1.f"i
13 t✓ S c� e. e,. b I vt„ d to % J e -
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.
s S3
DATE 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
and disposal system.
DATE SIGNATURE
DCHD (12-90)
` DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
NAME T�"O DATE EVALUATED a Z - %3
ADDRESS S AMt� `� PROPERTY SIZE I06 k 1 9S X /�,O' k I�-;1
PROPOSED FACIILTY �`� " a'n�- LOCATION OF SITE G CM�')' \A
Water Supply: On -Site Well
Evaluation By' -CCL Auger Boring
Community
L-1 Pit
Public
Cut
FACTORS
1
2
3
4
Landscape position
-5
S
s
-�
Sloe 7.
c5- -c- 1�
o - 2m
O -Z%
HORIZON I DEPTH
L� "
/.2 1,
/
Texture group
I_
C
L
CL
Consistence
F -L
f-
F:1
FM
Structure
C
Q R
Mineralogy
I°1
l'
HORIZON II DEPTH
�i1
Z
6
6
Texture group
Consistence
' -
F 7
FT
Structure
�G
6�4 K
At3k
Mineralogy
HORIZON III DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
S5
5S
_5_5
RESTRICTIVE HORIZON
-
-
-
SAPROLITE
--
-
-`
CLASSIFICATION
T75
LONG-TERM ACCEPTANCE RATE
,4
SITE CLASSIFICATION: ly . S'
LONG-TERM ACCEPTANCE RATE: —
REMARKS:�� ► I
DCHD (01-901
EVALUATED BY: C�1�
OTHER(S) PRESENT:
a -
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 -Firth 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