1920 Angell Rd (2)t` ` FAL,
DAVIE COUNTY HEALTH. DEPARTMENT
C- "� • IMPROVEMENTS PERMIT AND CERTIFICATE OF. -COMPLETION rm , 1;3v
*NOTE: Issued in Compliance With Article II of G.S. Chapter 130a .----
S nitary Sewage stems� P Omit Number
Name , 1 A s rk _ Date 5 4 N_ 7566
Location �_�_ � o at_
t
Subdivision Name Lot No. Sec. or Block No.
Lot Size' House Mobile Home Business __ Industry
No. Bedrooms No. Baths ""No,,in Family _ Public iAssembly Other
Garbage Disposal YES ❑ NO- (� Specifications 11 for, System�
Auto Dish Washer YES' ❑ NO ® / oo ,0 ct..p
Auto Wash Ma^hine YES NO ❑. � k x 2 r
Type Water Supply
*This permit Void if sewagersystem 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. {,
•
Y'
Improvements permit byu,R�-
*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 bf completion. Telephone Number-�704-634-5985.
Final Installation Diagram: System Installed by _ V
Y 3
1 �
c✓rt
i
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Y
(44
0 9 n�
e of Complet....
Certification �y 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.
V
s DAVIE. OUN�Y HEALTH DEPARTMENT a
IMPROVEMENTS 'PERMIT .AND CERTIFICATE OF COMPLETION
"Note: Issued in Compliance with G.S. of -North Carolina Chapter 1.30—Article 13c.
Permit Number
i
Name tU_�► 1, c� .�.r�ace, i Date /� -77
�2. ��
Location fi ��a �. �/ �, r� �,/ ,! �i' f' `fir ��<, �-` - (. 5 )
/• Fit✓_ AWD �r%.e fLGjl� s`1� + k J •
Subdivision Name �!° Lot No. Sec. or Block No.
Lot Size E —House-^"" Mobile Home '_ Business Speculation
No. Bedrooms No. Baths No in -Family
Garbage Disposal YES❑ NO,g,-'
,g,'
i. Specifications for. System: «, Tom, S •T .
Auto Dish Washer YES ❑ NO I
Auto Wash Machine YES g --NO p ' t�. 3 2 v
Type Water Supply it ! Jh !� _
*This: permit Void if sewage system described below is not installed within 36 months from date of issue.
IPA
}t l f
1�
+ Improvements. permit by Q. nwd
�t O
*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: 704-634-5985.
Final Installation Diagram:
0.
System Installed by `c[ hla'
Si
X3 /2-k/"
Certificate of Completion d'. Date 11-2 7-29
*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.
l ^ APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section fc9
P O B 665 W
Mocksville, NC 27028
MAR - 3 1991
Applicatio Permit Requested By
Mailing Address <k Home Phone
'lti C— a -"l C) C3 f Business Phone QI c) - �( U
2. Name on Permit if Different than Above
3. Application for:
4. System to Serve:
❑ Business
4FOenerall Evaluation
'house
❑ Industry
5. If house, mobile home: Subdivision
❑ Septic Tank Installation Permit
❑ Mobile Home ❑ Place of Public Assembly
❑ Other ❑ Unknown
No. of People �--
No. of Bedrooms -3
No. of Bathrooms ll
Dwelling Dimensions DD 0 W
bv
6. If business, industry, place of public asse bly, 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: ❑ Public �rivate
8. Property Dimensions 1 Sewage Disposal Contractor
9. Do you anticipate additions/expansion of the facility this sytem is intended to serve?
If yes, what type?
Section Lot #
❑ Basement/Plumbing
❑ Basement/No Plumbing
UY(Alashing Machine
❑ Dishwasher
❑ Garbage Disposal
❑ Yes ❑ No
❑ 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:
6 -�L/
•m �� .�a 73 6
Gvo,r ,� f�i Z351 � �Z 9 / — '7 AM —
This is to certify that the information provided is correct to the best of my
incurred from this application.
DATE
and I understand I am responsible for all charges
SIGNATURE
CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED
PROPERTY
[3R
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,�t� a Davie Coun"ealt Department to enter upon above described
property located in Davie County and owned by P� C)�. .
to conduct all testing procedures as necessary to determine s id site's suitalAity for a ground absorption sewage treatment
and disposal system.
3,a-1�1)-\
DATE SIGNATURE
DCHD (1193)
DAVIE COUNTY HEALTH DEPARTMENT
ENVIRONMENTAL HEALTH SECTION
P.O. BOX 57 ,v
S-' MOCKSVILLE, N.C. 27028 b'`� • S
(704) 634-5985
STATEI+iENT FOR SEPTIC TANK IMPROVEME11TS PERMITS AND/OR SITE EVALUATIONS '()'
NAME �_n ,--j� �<.e.rL. DATE _ Z?,6 -- "T $
ADDRESS{_T^��� _ PERMIT NO. _??
! IC. :2V677
EXPLANATION OF CHARGE
AMOUNT DUE � SANITARIAN
PLEASE REMMMT THE ABOVE AMOUNT OF RECEIPT OF THIS STATEMENT.
*NOTICE: Evaluation(s) can not be coroleted until payment'is received.
Improvements Permit(s)-can-not be issued until payment is received.
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REVISIONSDATE
TY, N. C.
aps 17
00'
3� 3-4
MAP
No. E-'
E&
DAVIE COUNTY HEALTH DEPARTMENT
' Environmental Health Section
Soil/Site Evaluation
NAME e�\y DATE EVALUATED ?J
ADDRESS S P `:� Q PROPERTY SIZE Qy�
PROPOSED FACIILTY �� LOCATION OF SITE RA
Water Supply: On -Site Well " Community
Evaluation ByC �L- Auger Boring ✓ Pit
Public
Cut
FACTORS
1
2
3
4
Landscape position
.S
S
Sloe %
o- 0
0 -'Zi°
O -$°
O
HORIZON I DEPTH
Jam"
_::''
1-.'
FD'
Texture group
C,CL
C L
L
Consistence
F`
__j -
Structure
Q�' 1?1
T
Mineralogy
',
V
1'I\
HORIZON II DEPTH
Texture group
C
C
C
C
Consistence
Z
StructureMineralogy
HORIZON III DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
s
S s
S�
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE
��
3
SITE CLASSIFICATION: q 's
EVALUATED BY:
LONG-TERM ACCEPTANCE RATE:`
3 OTHER(S) PRESENT: 'z
REMARKS: %S��
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
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(01-901