1886 Angell RdJ 44
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DAVIE COUNTY HEALTH
DEPARTMENT
°:160,
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IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION ,
*NOTE: Issued in Compliance With Article I I of G.S. Chapter 130a
tntary Sewage Systems
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Permi
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Subdivision Name Lot No. Sec. or Block No.
Lot Size __ House Mobile Home Business Speculation
No. Bedrooms No. Baths No..in Family
Garbage Disposal YES p NO gpecificatiogs;for System:
Auto Dish Washer ' YES NO p
Auto Wash Ma shine YES 12 NO
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.
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'Contact a representative of the Davie County Health Department for filial inspection of this system between 8:30-
9:30 A.M. or 1:00-1:30 P.M. on day of completion. Telephone Number 704-634-5985.
Final Installation Diag
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System Installed by
\ Certificate of Completion �"'�-' Date
'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
satisfactorily for any given period of time.
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op,
1. Application/Permit
Mailing Address
APPLICATION FOR SITE EVALUATIONAMPROVEMENTS
Davie County Health Department
Environmental Health Section
P. 0. Box 665
Mocksville, NC 27028
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SEP 2 71993
ed By
r -a 1 Home Phone
TC_ �.'lao{, Business Phone /Qyo l D
2. Name on Permit if Different than Above
3. Application for. a General Evaluation -optic Tank Installation Permit
4. System to Serve: 14 -House ❑ Mobile Home ❑ Place of Public Assembly
❑ Business ❑ Industry ❑ Other ❑ Unknown
5. If house, mobile home: Subdivision Section Lot #
No. of People
No. of Bedrooms
No. of Bathrooms ,--
Dwelling Dimensions �1D
6. If business, industry, place of public assemb y, other: Specify type
No. of People Served
No. of Commodes
No. of Lavatories
No. of Sinks
No. of Urinals
No. of Water Coolers
❑ Basement/Plumbing
❑ Basement/No Plumbing
[Washing Machine
❑ Dishwasher
❑ Garbage Disposal
No. of Showers Water Usage Figures
7. Type of water supply: ❑ Public Private ❑ Community
8. Property Dimensions Sewage Disposal Contractor
9. Do yop anticipate additions/expansion of the facility this �ytem is intended to serve? ❑ Yes �"o
If yes, what type?
Il 'NOTE: Improvements Permits shall be valid for a period of 5�years from date issued. Improvements Permits are subject to II
revocation, if site plans or. the intended use change. Effective October 1, 1989.
Directions to Property:
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This is to ,certify that the information provided Is correct to the best of my knowledge, and I understand I am responsible for all charoes
Incurred from this application.
a "\'P -
DATE
CONSENT FOR SITE EVALUATION TO RE DONE QU ABOVEPROPERTY
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MUST CHECK ONE: 1. I Othe property. 622, 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:
1 hereby give consent to the authorized representative -of the Davie Counj Health Depart!ent to enter upon above described
property located in Davie County and owned byy
to conduct all testing procedures as necessary to determirid said site's s itability for a group bsorption sewage treatment
and disposal system.
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DATE SIGNATURE
DCHo v/93)
iDAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
NAME
ADDRESS
PROPOSED FACIILTY Rd J SO -
DATE EVALUATED
PROPERTY SIZE b>
LOCATION OF SITE
Water Supply: On -Site Well V Community Public
Evaluation By:Ct.1— Auger Boring �Pit Cut
FACTORS
1
2
3
4
Landscape position
S
Slope %
' 1 Su
' )5
HORIZON I DEPTH
b
Texture grOu2
C
C �-
Consistence
IF 7
Gx
Structure
C -I Z
2-
MineralogX;1
1
HORIZON II DEPTH
Texture group
Consistence
Structure
)L
<
Mineralogy
HORIZON III DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
S
SS
RESTRICTIVE HORIZON
✓
�-
SAPROLITE
-�
CLASSIFICATION
S
LONG-TERM ACCEPTANCE RATE
,L
y
SITE CLASSIFICATION:y
LONG-TERM
REMARKS:
-
DCHD(01-901
I
EVALUATED BY: r"_ - `_ '
OTHER(S) PRESENT:
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 -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
Mi neralojzy
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