P7661 Hwy 601DAVIE COUNTY HEALTH DEPARTMENT
r
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
-# NOTE: Issued in Compliance With Article I I of G.S. Chapter 130a
Sanitary Sewage Systems / Permit Number
Q/
Name ' %' �� / 7 .Ou,^�� Date N2 7661
_
Location � // - % SII✓.'l��Y /� ,/)
Subdivision Name Lot No. Sec. or Block No.
Lot Size �� House Mobile Home _A<' Business -- Industry
No. Bedrooms No. Baths —c�2 No. in Family Public Assembly Other
Garbage Disposal YES ❑ NO 2r Specifications for System:
Auto Dish Washer YES ❑ NO e/� /�
Auto Wash Ma thine YE�S7 �NO E]l'r-
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.
F
Improvements permit by —L1/
*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:
System Installed by
A
Certificate of Completion - Date
'The signing of this certificate shall indicate that the system described above has been installed in compliancN 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.
d� APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department j� R�,
Environmental Health Section u �► E -I-r-� Ll J VV If: tW
P. 0. Box 665
Mocksville, NC 27028 JUL 1 91994
1. Application/Permit Requested By
Mailing Address
2. Name on Permit if Different than Above
3. Application for:
4. System to Serve: ❑ House
Home Phone t/y34—,5445 1
�G L Business Phone
❑ General Evaluation
❑ Business ❑ Industry
5. If house, mobile home: Subdivision
No. of People
No. of Bedrooms
No. of Bathrooms
Dwelling Dimensions 4 8
Ergeptic Tank Installation Permit
Mobile Home ❑ Place of Public Assembly
❑ Other ❑ Unknown
6. If business, industry, place of public assembly, other: Specify type
No. of People Served
No. of Commodes
No. of Lavatories
No. of Showers
No. of Sinks
No, of Urinals
No. of Water Coolers
Water Usage Figures
Section Lot #
❑ Basement/Plumbing
❑ Basement/No Plumbing
�IVashing Machine
❑ Dishwasher
❑ Garbage Disposal
7. Type of water supply: p1Public ❑ Private ❑ Community
8. Property Dimensions //o �( 3 d Sewage Disposal Contractor
9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes ONo
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:b e:fi
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. ^
7- /,? - 9,. �
DATE �— SIGNATURE
CONSENT FOR SITE EVALUATION TQ BE DONE ON ABOVE DESCRIBED PROPERTY
MUST CHECK ONE: ❑ 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 represent tive of the Davie Coun Health Department to enter upon above described
property located in Davie County and owned by —r
to conduct all testing procedures as necessary tf dete ine said site's suitability for a ground absorption sewage treatment
and disposal system.
DATE 'II' / SIGNATURE
DCHD (1/93)
�L
-._. DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
,,NOTE: Issued in Compliance With Article 11 of G.S. Chapter 130a - p
Sanitary Sewage Systems Permit Number
Name r e1 IlAnatA �%/�y N°J662
Location /%/ l' ..Pc
Subdivision Name 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 ❑ NO � Specifications for System:
Auto Dish Washer YES ❑ NO D'
Auto Wash Ma^hine YES NO ❑ �u
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.
d rV
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:.
System Installed by
9-- - , - - - ��.1
Certificate of Completion G�caGl-/ 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
,YEnvironmental J U'E D
Health Section
-,
P. O. Box 665Mocksville, NC 27028
JUL 19it.-!
r
1. Application/Permit Requested By
Mailing Address
Home Phone 634-..x545 1
Business Phone
2. Name on Permit if Different than Above
3. Application for:
4. System to Serve:
❑ Business
❑ General Evaluation
❑ House
❑ Industry
5. If house, mobile home: Subdivision
No. of People 7
No. of Bedrooms .3
No. of Bathrooms 7
Dwelling Dimensions ��, 4 8
Septic Tank Installation Permit
EMobile Home ❑ Place of Public Assembly
❑ Other
6. If business, industry, place of public assembly, other: Specify type
No. of People Served
No. of Commodes
No. of Lavatories
No. of Showers
No. of Sinks
No. of Urinals
No. of Water Coolers
Water Usage Figures
7. Type of water supply: B'Public ❑ Private
8. Property Dimensions 110 < ---? dy Sewage Disposal Contractor
9. Do you anticipate additions/expansion of the facility this sytem is intended to serve?
If yes, what type?
❑ Unknown
Section Lot #
❑ Yes
❑ Basement/Plumbing
❑ Basement/No Plumbing
"ashing Machine
❑ Dishwasher
❑ Garbage Disposal
❑ 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: b :-6 �
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.
7- /g-- 9 i
DATE A SIGNATURE
CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY
MUST CHECK ONE: ❑ 1. 1 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 represent tive of the Davie Cou Health Department to enter upon above described
property located in Davie County and owned by LAAO,-
to conduct all testing procedures as necessary tf detertnine said site's suitability for a ground absorption sewage treatment
and disposal system.
DATE /i / SIGNATURE
DCHD (1/93)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
NAME 0�2i` Z /
ADDRESS
PROPOSED FACULTY�Ar,�e
DATE EVALUATED
PROPERTY SIZE,��i%G
LOCATION OF SITE �2V/S'
Water Supply: On -Site Well Community Public
Evaluation By: Auger Boring ✓ Pit Cut
FACTORS 1 2 3 4
Landscape position
Slope %
HORIZON I DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH
Texture group(�
Consistence
Structure Ale 1574
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 , L ,
SITE CLASSIFICATION:
LONG-TERM ACCEPTANCE RATE:
REMARKS:
DCHD(01-901
EVALUATED BY: �Z6 /,Z
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 <.lay 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
5C -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
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
l Soil/Site Evaluation ►�
NAME �/��j/1�/C/� DATE EVALUATED /1�/��
ADDRESS PROPERTY SIZE
PROPOSED FACIILTY LOCATION OF SITE
Water Supply:
On -Site Well
Community
Public
Evaluation By:
Auger Boring_111_�_
Pit
Cut
FACTORS 1
2 3 4
Landscape position
,L
Sloe Z �—
HORIZON I DEPTH
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
LONG-TERM ACCEPTANCE RATE V
,
SITE CLASSIFICATION: _ 1iJ� EVALUATED BY: __ ZZ
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 -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
3C -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