P6228 Baileys Chapel RdDAVIE- COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTE: Issued in Compliance With Article 11 of G.S. Chapter 130a
Sanitary Sewage Systems f�,. F- Permit Number
Name<�` �/ < i'i`i l �;'r r sir -ter, i !'�'`i -Date /c 0 6228
N.
Location �/1 ,�r'�'% k'� ,/� rr 4it'/1 / / % i1 /S' ✓��✓�';ti :, 'b v
Subdivision Name Lot No. Sec. or Block No.
Lot Size ! �r<< House Mobile Home _ Business Speculation
No. Bedrooms No. Baths No. in Family
Garbage Disposal YES ❑ NO p'' Specifications for System:
Auto Dish Washer YES NO ❑ IGU ,., l } „J r! i ,�
Auto Wash Machine YES [ NO ❑ c 1 r; 7.
Type Water Supply �> _
y 5 `X 3
*This permit Void if sewage system described below is not installed within 9—years from date of issue.(:
This permit is subject to revocation if site plans or the intended use change. 7- 5
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: 704-634-5985.
Final Installation Diagram:
System Installed by
Ever' /O �
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.
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
i; Davie County Health Department
Environmental Health Section RECEIVED DEC 0 5 191
P. 0. Box 665
Mocksville, NC 27028
1. Application/Permit Requested By r0J3 2?T 5 Fu i L DF a S
Mailing Address 2t). 4" N J4 cty A AJ GI _ )V C, 9 Ivo G
Home Phone /y8- 3 4 S Business Phone 9?9 3 �S
2. Name on Permit if Different than Above
3. Property Owner if Different than Above
4. Application/Permit For: W/General Evaluation
5. System to Serve: 2 -House Mobile Home
❑ Industryu Other
6. If house, mobile home:
Subdivision
0 S/Tank Installation
0 Business
0 Unknown
Sec. Loth
No. of People Dwelling Dimensions
No. of Bedrooms ,Basement/Plumbing
No. of Bathrooms. / Basement/No Plumbing
Washing Machine 0 Dishwasher 0 Garbage Dasposai
7. If business, industry, other: Specify type
No. of People Served
No. of Commodes
No. of Lavatories
No. of Showers
8. Type of water supply: g -Public
9. Property Dimensions OVER VQ bao
10. Sewage Disposal Contractor
No. of Sinks
No. of Urinals
No. of Water Coolers
0 Private 0 Communi. y
11. Do you anticipate additions/expansions of the facility this system is
intended to serve? 0 Yes . p—No
If yes, what type?
+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.
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. Q
Date Signature
DirecL..oni to Property:
SD i ' 1,4 F� G//R1�-� 1�d
,C o % JFS i wFr ,v o2 4 3 140 Lt -5 6- v,u R 7 ;
DCHD (10-89)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
NAME
ADDRESS
PROPOSED FACIILTY
Water Supply:
Evaluation By:
DATE EVALUATED "g2 -e'l -&
PROPERTY SIZE
LOCATION OF SITE �IQi/LAG/ L�l.e�
On -Site Well Community
Auger Boring Pit
Public
Cut
FACTORS
1
2
3
4
Landscape position
2-
-
Slope
S1o e %
'L/
- r�
HORIZON I DEPTH
41G
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH
Texture group
Consistence
-�
Structure
Mineralogy
HORIZON III DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
S
LONG-TERM ACCEPTANCE RATE
SITE CLASSIFICATION: 1J� S . EVALUATED BY:
LONG-TERM ACCEPTANCE RATE: / OTHER(S) PRESENT:
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
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 -Film 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 watef 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/fU
DCHD (01-901