430 Oakland Avenue Lots 73-74DAVIE COUNTY HEALTH DEPARTMENT
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IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTE: Issued in Compliance With Article 11 of G.S. Chapter 130a ,
- Sanitary Sewage Systems Permit Number
1--.,
NO 7481
Name Date
Location
LL
Subdivision Name 01 No. LotL'
< Sec. or Block No.
> U 6,
Lot Size -3 House Mobile Home Business --- Industry
No. Bedrooms No. Baths No. in Family' Public AssemblyOther
Garbage Disposal YES C] NO 03' Specifications for System:
Auto Dish Washer YES 0' NO E]
Auto Wash Ma-.hine YES Ef NO C]
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.
0 (3"'
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 completion. Telephone Number: 704-634-5985.
Final Installation Diagram: System Installed by
tj J
Ce.rtificato of
9
*The signing of this certificate shall indicate that the
the standards set forth in the above regulation, but sK
satisfactorily for any given period of time.
C o 'We tion SS �'' Date
,,yst7m described above has been installed in compliance with
,11 in NO waybetaken as a guarantee that the system will function
Y
APPLICATION FOR SITE EVALUATIOWIMPROVEMENTS
Davie County Health Department
Environmental Health Section 11AR 1 01994
P. O. Box 665
Mocksville, NC 27028
1. Application/Permit Requested By
Mailing Address 1) 15 Rn a t I / Home Phone ti 0 Li) p-. 7 q - 313 Del
d l i E i. l `i In Business Phone /0.734 - a149 I
2. Name on Permit if Different than Above
3. Application for: 0 General Evaluation Septic Tank Installation Permit
4. System to Serve: A House ❑ Mobile Home ❑ Place of Public Assembly
❑ Business ❑ Industry ❑ Other ❑ Unknown
5. If house, mobile home: Subdivision GlniP.i`T}�> Section Lot #x1375
No. of People 2
No. of Bedrooms (7r
No. of Bathrooms 12
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 d (Z i�Q� Sewage Disposal Contractoi
9. Do you anticipate additions/expansion of the facility this sytem is intended to serve?
If yes, what type?
❑ Basement/Plumbing
❑ Basement/No Plumbing
Washing Machine
Dishwasher
❑ Garbage Disposal
❑ Yes X No
'A 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:
Coq \i\ft?s+ -6 Uav l e AcAerny R,00l —Fu f n � e,-4 orl
Davit AcalerrN - Go -k scconl R 1 (00,1r-1aAA /-fVeG u)e-
IL-
IY I(` �—f�I .1�
l o -k are- o n 4c- l e-l�`t-. 1 h 1✓ cfm *4 e Three [ 0 f 3
I 1 II (� �I I ( � 1 I
r`1 n� bee re- +-h2 Fri Qb► I£ hDmeS S �a,r`f -
This is to certify that the information provided is correct to the best of my knowledge, and 1 understand I am responsible for all charges
incurred from this application.
mctrc� C11 M14
DATE
CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY
MUST CHECK ONE: P/1. 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 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 (1193)
*40
r `^ DAVIE COUNTY HEALTH DEPARTMENT
✓ Environmental Health Section
Soil/Site Evaluation
NAME y ` ¢ ��� DATE EVALUATED
ADDRESS S A r�P PROPERTY SIZEy� on x 20 0
\ \ la's
PROPOSED FACIILTY o`� S� LOCATION OF SITE (7� C;Sk�
Water Supply: On -Site Well
Evaluation By:_.,!,_1, Auger Boring i�
Community V Public
Pit
Cut
FACTORS
1
2
3
4
Landscape position
Sloe 7.
S
6_ 'Co
s
HORIZON I DEPTH
Texture group
Consistence
Z
Structure
2-
Mineralogy
HORIZON II DEPTH
D'.
D
2
Texture groupC
Consistence
5
-
Structure
B
K
Mineralogy1
' i
HORIZON III DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
5 7S
�S
RESTRICTIVE HORIZON
-
—
r
SAPROLITE
—
-'
CLASSIFICATION
S
,S,
,S
P s
LONG-TERM ACCEPTANCE
RATE ,
Itl
11A�-}
SITE CLASSIFICATION: 5 EVALUATED BY:
LONG-TERM ACCEPTANCE RATE: 1 OTHER(S) PRESENT:"*'-ti--_-S�
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
'r -ill -
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
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/ftz
DCHD (01-901