171 Dayspring Wayl
DAVIE COUNTY HEALTH DEPARTMENT o
',.� - - (1tPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTE: Issued -in Compliance With Article II of G.S. Chapter 130a
Sanitary Sewage Systems Permit Number
Name `.: , �� t-\ �� `\..: .. ,�� -- Date - Y _ f N2 7871
Location
•) .5.+ " "� ♦ ;,.) T 4
Subdivision Name Lot No. Sec. or Block No.
Lot SizeHouse _ Mobile Home ---- Business _— Industry
No. Bedrooms --4--. No. Baths _=— No. in Family -% — Public Assembly Other
Garbage Disposal YES [f NO ❑ SP ecifications for System:
Auto Dish Washer YES p NO ❑ f Lac
Auto Wash Ma shine YES [Z NO ❑ }� w
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
^ ATTENTION: YOUR SEPTIC SYSTEM CONTRACTOR MUST SEE THIS PERMIT/LAYOUT BEFORE INSTALLING THIS
SYSTEM.
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.,
1:00-1:30 P.M. or 4:30-5:00 P.M. on day of completion. Telephone Number: 704-634-5985.
Final Installation Diagram: J�'I \I� �� i � v System Installed by
u
1 01
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
•
Davie County Health Department( ( 10- V! r�
i�
Environmental Health Section
P. O. Box 665 JA
1J 1995
Mocksville, NC 27028
r
- J-
1. Application/Permit Requested By C3y1 A.d.ct?
,T- l��
Mailing Address 1/0 IJ (I/d/d d4
1 CO• Home Phone Q 1) X11- 57 '(",f
_YV7 rm-L 14L
C. X70 a S Business Phone ?QV - S i
2. Name on Permit if Different than Above
3. Application for: ❑ General
Evaluation peptic Tank Installation Permit
4. System to Serve: ErHouse
❑ Mobile Home ❑ Place of Public Assembly
❑ Business ❑ Industry
❑ Other ❑ Unknown
5. If house, mobile home: Subdivision
Section Lot #
❑ Basement/Plumbing
No. of People -3
❑ Basement/No Plumbing
No. of Bedrooms -
O'(Nashing Machine
No. of Bathrooms .2- r
LzYdishwasher
Dwelling Dimensions
42 -Garbage Disposal
6. If business, industry, place of public assembly,
other: Specify type
No. of People Served
No. of Sinks
No. of Commodes
No. of Urinals
No. of Lavatories
No. of Water Coolers
No. of Showers
Water Usage Figures
7. Type of water supply: ❑ Public
P -Private ❑ Community
8. Property Dimensions Lf.rJl n
Sewage Disposal Contractor
9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes EI -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.
Directions to Property:
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�L -- -- Ran dz J ? 20�
DATE SIGNATURE
CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY
MUST CHECK ONE: C-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
to conduct all testing procedures as necessary to determine said site's suitability for a ground absorption sewage treatment
and disposal system. p
�- 44- 94 iii /l . 6Y1 a.Pd �7 ��Of.te
DATE SIGNATURE
DCHD (1/93)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
NAME go Nib \ 'o
ADDRESS S A M 'Q
PROPOSED FACIILTY YA 0 y "`fz
DATE EVALUATED
PROPERTY SIZE
LOCATION OF SITE bUI-4 Ay
Water Supply: On -Site Well 1/ Community Public
Evaluation By:C Auger Boring Pit Cut
FACTORS
1
2
3
4
Landscape position
Sloe 7-
��
-3�
S 30
is -3 6
HORIZON I DEPTH
Texture group
C L
C L
C L
Z -
Consistence
FZ
1-
FZ
Structure
Mineralogy
):
I'
11)
HORIZON II DEPTH
Hi L
Texture group
C
Consistence
tr
1 Z
Structure
Q
@
Mineralogy
)
HORIZON III DEPTH
Texture group
Consistence
•
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
-
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE
,r$
SITE CLASSIFICATION: fl�' 5 EVALUATED BY:
LANG -TERM ACCEPTANCE RATE: OTHER(S) PRESENT:
REMARKS: U r
LEGEND
Landscave 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
- r
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
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