369 Hillcrest Dr (2)DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTE: Issued in Compliance With Article II of G.S. Chapter 130a
Sanitary Sewage Systems Permit Number
Name Date /`%� N2 6173
Location •�'�� ' ��� ..�I i' %r' /Jfra %� ;,;r, -, �r �� �!7
i— —
Subdivision Name Lot No. Sec. or Block No.
fi%
Lot Size � House —I-- Mobile Home — Business _— Speculation
y { No. Bedrooms— No. Baths No. in Family_
Garbage Disposal YES NO ❑ Specifications for System:
Auto Dish Washer YES NO ❑
Auto Wash Machine YES NO ❑
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 g0he n ded use cha ge—
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
0^
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.
2.
3.
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section ��n
P. 0. Box 665 SEP
Mockaville, NC 27028 RECEI��++� .
Application/Permit Requested By
Mailing Address
Home Phone lousiness Phone
Name on Permit if Different than Above
Property Owner if Different than Above
4. Application/Permit For: 0 General Evaluation 0 S/Tank Installation
5. System to Serve: 13/House u Mobile Home 0 Business
Industryu Other 0 Unknown
6 f house, mobile home: Subdivision l/ Sec. Lott
No. of People Dwelling Dimensions
No. of Bedrooms Z.-fsasement/Plumbing
No. of Bathrooms_ [ ,Basement/No Plumbing
g,Washing Machine Dishwasher Garbage Disposai
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: 0 Public
9. Property Dimensions I 4-'e
10. Sewage Disposal Contractor
No. of Sinks
No. of Urinals
No. of Water Coolers
0 Private
0 Community
11. Do you anticipate additions/expansions of the facility this system is
intended to serve? [],Yes t0/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 plane 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 understan I am responsible or all
charges incurred from this applicati
�Uat Signature
Directions to Property:
DCHD (10-89)
Davie County Health Department
Environmental Health Section
Site Evaluation Consent Form
LOCATION OF PROPERTY: DATE RECEIVED
9dZ 4nd Ax,::,�� a. A44r) (office use only)
oy�s' no 1. 1 am the owner of thE above I described property.
yes no 2. 1 am not the owner of the above described property, however, I certify that I
have consent from , owner to obtain a
owner's name
site evaluation by the Davie County Health Department for the purpose of
determining the suitability for a ground absorption sewage treatment and
disposal system.
0yes no 3. 1 hereby give consent to the authorized representative of the Davie County
Health Department to enter upon the above described propertyand conductall
testing procedures as necessary to determine its suitability for a ground
absorption sewage treatment and disposal systerTf.
DATE SIGNATORE
4. 1 hereby authorize the Davie County Health Department to release site
evaluation resu ts from the above described property to the following:
Owner only
— Owners designated representative
— Anyone requesting results
— Only those l!stbd,,below,
q-//-Zj
DATE -
DCHD (11 /84)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
NAME &261Ll
ADDRESS
PROPOSED FACIILTY 4!!Z_4 "r {
DATE EVALUATED
PROPERTY SIZE
LOCATION OF SITED/
Water Supply: On -Site Well Community Public_ /%
Evaluation By: Auger Boring Lef::_� Pit Cut
FACTORS
1 2
3 4
Landscape position
L L
L
Slope %
4►
f"
HORIZON I DEPTH
Texture group
r4 I -/-
Consistence
Structure
MineralogX
HORIZON II DEPTH
Texture group
Consistence
Z1.1 1
Structure
A
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
SITE CLASSIFICATION:
LONG-TERM ACCEPTANCE RATE:
REMARKS:
DCHD(01-901
EVALUATED BY:
OTHER(S) PRESENT:
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 -Finn 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
■OMM■NN■
■EMENNO■
■UM■ENN■
■