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155 Cane Mill DrIMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION *NOTE: Lued in Compliance With Article 11 of G.S. Chapter 130a Sanitary Sewage Systems Permit Number Date N2 8036 Location Lot No. Sec. -or Block No. Lot Size —House --Mobile Home Business Industry_ No. Bedrooms ---.,,No. Baths — — — — No. in Family Public Assembly�_Other Garbage Disposal YES C] NO Cy Specifications for System: Auto Dish Washer YES 0 NO Ef Auto Wash Ma-hine YES NO0 L) Type Water Supply ^ ` This permit Void if sewage system described below is not installed within 5 years from date of issue. ' This permit iusubject torevocation ifsite plans orthe intended use change ATTENTION: YOUR SEPTIC SYSTEM CONTRACTOR MUST SEE THIS PERMIT/LAYOUT BEFORE INSTALLING THIS SYSTEM. ..` \ Improvements permit by / *Contact arepresentative ofthe Davie County Health Department for final Inspection of this system between 8:30-9:30 A.M., / 1:0O'1:3UP./N.n,4:30'5:D0P.K8.onday o(completion. Telephone Number: 704'G34'5Q85. Final Installation Diagram: / I System Installed by � ' � 7 ' ` ~ ' «~~/~ �~ ^� Certificate of ,Completion �Date 'The signing odthis 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 oftime. � z APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT Davie County Health Department Environmental Health Section P. O. Box 665 Mocksville, NC 27028 1. Application/Permit Requested By 7CZmeS" Mailing Address /-,& ea?1=' '6 " "J o Home Phone�� ' Business Phone 2. Name on Permit if Different than Above -- 3. Application for: a General Evaluation 4. System to Serve: ❑ House ❑ Business ❑ Industry 5. If house, mobile home: Subdivision /� &S' eptic Tank Installation Permit 2 Mobile Home ❑ Place of Public Assembly ❑ Other ❑ Unknown No. of People -s No. of Bedrooms -3 No. of Bathrooms Dwelling Dimensions% X52 6. If business, industry, place of public assembly, other: Specify type No. of People Served No. of Commodes No. of Sinks - No. of Urinals No. of Lavatories No. of Water Coolers . No. of Showers Water Usage Figures 7. Type of water supply: ❑ Public l Private 8. Property Dimensions a Sewage Disposal Contractoi 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? If vas what tvna9 Section Lot # ❑ Basement/Plumbing ❑ Basement/No Plumbing RIN' ashing 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: �p Ser ?;'s*:,r';� �c:,:i. A�;% � �., �i� 1,/:�J S'<;�/> C.r,� je�it>i� ►�i.-, - / W 'GImoY4, -%o 46end Cul _r i ,PF t J 1CA 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. DATE elf SIGNATURE CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY MUST CHECK ONE: 2/1 - I 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 the Davie County Health Department to enter upon above described property located in Davie County and owned by Z�rna's 6 ),o", -/-" = � r 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 (1193) 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. DATE elf SIGNATURE CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY MUST CHECK ONE: 2/1 - I 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 the Davie County Health Department to enter upon above described property located in Davie County and owned by Z�rna's 6 ),o", -/-" = � r 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 (1193) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation NAME ZZ DATE EVALUATED ADDRESS Q'�e PROPERTY SIZE Gc�� PROPOSED FACIILTY "b Q LOCATION OF SITE Water Supply: On -Site Well v _ Community Evaluation Bytk,L Auger Boring Pit Public Cut FACTORS 1 2 3 4 Landscape position Sloe Z HORIZON I DEPTH Texture groupI_ C - Consistence Structure Mineralogy ' A\: HORIZON II DEPTH t-12" IA-)% Texture groupC Consistence Structure Mineralogy HORIZON III DEPTH Texture group Consistence Structure Mineralo HORIZON IV DEPTH Texture group Consistence Structure - Mineralogy SOIL WETNESS 5 fS RESTRICTIVE HORIZON ^ SAPROLITE r- �-- CLASSIFICATION S S LONG-TERM ACCEPTANCE RATE ` SITE CLASSIFICATION: � ' S LANG -TERM ACCEPTANCE RATE: REMARKS: DCHD(01-901 �� LEG EVALUATED BY: OTHER(S) PRESENT: 0) A n 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 :lay loam, SIL -Silty loam CL -Clay loam SCL-Sandy clay loam SC -Sandy clay SIC -Silty clay C -Clay CONSISTENCE Moist VFR- V+ ---y 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