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263 Southwood Drive Lot 8 Section BDAVIE COUNTY HEALTH DEPARTMENT ;• IMPROVEMENTS PERMIT AND CERfIFiCATE OF COMPLETION *NOTE: Issued in Compliance With Article 11 of G.S. Chapter-'3ba Sanitary Se/wage SystemsPermif Number Name!/�l>/G/��i/�,,., �9,F Date_ N27525 �a Subdivision Name–Y>u�� Lot No. Sec. or Block No. Lot Size �` House L�--''n Mobile Home " '"Business —' Industry No. Bedrooms s.No. Baths �.L / No.. in Family-- Public Assembly I Other Garbage Disposal YES ❑ NO g�' Specifications for System: Auto'Dish Washer YES NO ❑s, Auto Wash Machine YES NO ❑. A�e�e� 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 completion. Telephone Number: -704-634-5985. Final Installation Diagram: Installed by_ –_, .I �M µ f Irl _U k .. Certificate of Completion At Date v/' AG �9L� `The --signing ,of thiscertificate shall indicate that the system described above has been installed in -compliance with ` the standards set forth in the above regulation,, butshall in NO way be taken as a guarantee that the system will function satisfactorily for any given period of time. t v Y Y "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: Installed by_ –_, .I �M µ f Irl _U k .. Certificate of Completion At Date v/' AG �9L� `The --signing ,of thiscertificate shall indicate that the system described above has been installed in -compliance with ` the standards set forth in the above regulation,, butshall in NO way be taken as a guarantee that the system will function satisfactorily for any given period of time. APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT Wt Davie County Health Department d FU ®Environmental Health SectionP. O. Box 665 -IPMocksville, NC 27028 C 15 M PIP 1. Application/Permit Reques ed By A271, Mailing Address 9 aAlde e_/ /Y a ✓f. Home Phone 2. Name on Permit if Different than Above 2 3. Application for: General Evaluation 4. System to Serve: F House Business ❑ Septic Tank Installation Permit ❑ Mobile Home ❑ Place of Public Assembly ❑ Business ❑ Industry // ❑ Other ❑ knor D S. If house, mobile home: Subdivision �4�7 Gr b✓DD C i2BS Section es/l Lot # 0 jp BasemenVPlumbing No. of People No. of Bedrooms No. of Bathrooms Dwelling Dimensions �G�rLcGLcO/ 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: Publicd ❑ Private 8. Property Dimensions �� / 9O ) Sewage Disposal Contractor ❑ Basement/No Plumbing Washing Machine Dishwasher ❑ Garbage Disposal 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: I- %Qi✓l 7�4 4>` 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 1 incurred from this application. s-93 0&0 DATE SIGNATURE 61 CONSENT FOR SITE EVALUATION TQ BE DONE ON ABOVE DESCRIBFA PROPERTY MUST CHECK ONE: ❑ 1. 1 OWN the property. 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 opoe Davie CounHealth department to enter upon above described property located in Davie County and owned by Y /jn// t Y 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 (1/33) Y TY HEALTH DEPARTMENT t VA COU11 Environmental Health Section r ' Soil/Site Evaluation NAME ADDRESS PROPOSED FACULTY DATE EVALUATEDIc;2 � PROPERTY SIZE LOCATION OF SITE S--;4v,4e,-e r Water, Supply: Evaluation By: .On -Site Well Auger Boring f Community .Pit' - Public Cut FACTORS 1 2 3 4 Landscape position Slope X HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH Texture groupG- Consistence Structure L Mineralogy/ HORIZON III DEPTH Texture grou Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL.WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE ' SITE CLASSIFICATION: / EVALUATED BY: A C/ - LDNG-TERM ACCEPTANCE RATE: OTHER(S) PRESENT: REMARKS: DCHD(01-901 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 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 ` Dam? County Ylealbf , Department and Noine Nealt§ :. yency 210 HOSPITAL STREET/ P.O. BOX 665 MOCKSVILLE, N.C. 27028 PHONE: (704) 634.5985 December 23, 1993 Anita Long 201 Wandering Lane Mocksville, NC 27028 Rei Site Evaluation Southwood Acres/Block B -Lot 8 Dear Ms. Long: As requested, a representative from this office visited the aforementioned site on December 22, 1993. Based upon the information provided on the application for a 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