360 Boxwood Church Rd (2)D"IE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
N OTE� I ssued i n Corn p I ian ce With Article I I of G.S. Ch apter 130a
Sanitary Sewage Systems Permit Number
Name �i 1�"\-) CAA Date N2 6155
Location
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 E] NO Ep S ecifications for System:
Auto Dish Washer YES'[:] NO
Auto Wash Machine YES N 0
x
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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,I!
Id
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_FnL.T_k,�L Z�QAsrjo
Q
Certificate of Comple�t n —Date
'The signing of this certificate shall indicate that the system d ribed aboias b4en installed�'Jn compliance with
the standards set forth in the above regulation, but shall in NO betakena!V guarantee that the system will function
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satisfactorily for any given period of time. > W
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section
-A P. 0. Box 665
Mockoville, NC 27028
C 4
1 Application/Permit Requested By 0
Mailing Address <-f- - '1 66)( S-16 -MW-*�W
Home Phone' Business Phone �6 3 1/
2. Name on Permit if Different than Above
4
3. Property Owner if Dif f erent than Above -5 401% % A. 12 ke Q
4. Application/Permit For: 0 Ge6eral Evaluation Q��/Tank Installation
5. System to Serve: House k1l'obile Home 0 Business
Industry
L - Other 0 Unknown
U
6. If house, mobile home: Subdivision Sec. Lot#
No. of People _LJ Dwelling Dimensions J4 S� 7L
No. of Bedrooms �3 Basement/Plumbing
No. of Bathrooms 1:1- 7 Basement/No Plumbing
@,,<ashing machine
0 Dishwasher 0 Garbage Disposal
7. If business, industry, other: Specify type
No. of People Served
No. of Commodes
No. of Lavatories
No. of Showers
S. Type of water supply: g..- �ublic
No. of Sinks
No. of Urinals
No. of Water Coolers
0 Private
9. Property Dimensions A �e-
d',�sal CoAtra�—toI7 +-k-
4'
1b. Sewage Di p
C) Community
11. Do you anticipate additions/expans ions of the facility this system is
intended to serve? [] Yes Lr�,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 tnat tne information provided is correct to tne
best of my knowledge, and I understand I am responsible for all
charges incurred from this application.
Ig— �0 AMAA
Date Signature
Directions to Property:
DO 4Wbl�-
14 L/jy
-Y I
-5 R ' 6, \ni-
DCHD (10-89)
13'e %I - )�
.�, % s
DAVIE COUNTY HEALTH DEPARTMENT
ENVIRONMENTAL HEALTH SECTION
SITE EVALUATION'CONSENT FORM
1. Complete the form'below and return to the Davie County Health Department.
2. Carefully follow the procedures as outlined in the enclosed "Information Bulletin."
NOTE: THE ABOVE MUST BE COMPLETED BEFORE A SANITARIAN WILL BE ABLE TO
BEGIN THE REQUESTED EVALUATION..
DETACH -HERE AND RETURN TO: Davie C66hty-Heiath-Departm'ent, Environmental ------------
Health Section, P. 0. Box 665, Mocksville, N.C. 27028
Davie County Health Department
Environmental Health Section
Site Evaluation Consent Form
LOCATION OF PROPERTY: DATE RECEIVED
1(3_6y-1W6bA CkAQC� PIS &J (office use only)
yes 1. 1 am the owner of thE above described property.
no 2. 1 am not the owner of the above described property, however, I certify that I
have consent from—W� 14 6-44-t-4oa- Morr,04ek.-PI
owner to obtain a
I -owner's nime I
site evaluation by the Davie County Health Department for the purpose of
determining the suitability for a ground absorption sewage treatment and
disposal system.
no 3. 1 hereby give consent to the authorized representative of the Davie County
Health Departmentto enter upon the above described propertyand conductall
testing procedures as necessary to determine its suitability for a ground
absorption sewage treatment and disposal system.
DATE
SIGNATURE
4. 1 hereby authorize the Davie County Health Department to release site
evaluation results from the above described property to the following:
— Owner only
—0 rs designated representative
nyone requesting results
— Only those listed below
DATE
DCHD (11 /84)
FA'
SITNARUFTL
NAME—
ADDRESS
PROPOSED FACIILTY
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
DATE EVALUATED '9 - ag -'7 D
PROPERTY SIZE
r\
LOCATION OF SITE __.. Q�,
Water Supply:
On -Site Well
Community
Public—
Evaluation ByC.��,
AugerBoring
Pit
Cut
FACTORS
2
3
4 5 6
Landscape position
--7S'—
.5
__�i --
Slope %
C) -
KCC_*L
O -Z
HORIZON I DEPTH
4�' if
Texture group
C L
L
Consistence
-
Structure
Mineralogy
HORIZON II DEPTH
L)o
14 0"
Texture group
el
I
<_*
Consistence
IF'r
V_T
Structure
Mineralogy
HORIZON III DEPTH
Texture grou2
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE
_2,.LA- _kLb
_2tC - J,
:5A; Ajo I
_-S& -ao
SITE CLASSIFICATION: 11�_' _:�> EVALUATEDBY: Q31.11_zsm� lt�'�
LONG-TERM ACCEPTANCE RATE: D OTHER(S) PRESENT:
REMARKS:
LEGEND
Landscape Position
R -Ridge S -Shoulder L-�-Linear slope FS-Footslope 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-Loarn 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:i, 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 wateC 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