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4427 Hwy 64Wt � , :s::�vf,{t .:. �. m •� +e....if.'�>;Y'+>o>s _✓:4c°v ti+ity .l:rV'. Lam;;. r'.. `5r +. sS d' i''i�"j... wTa j `....�,,.�., '� r`��...: �� .y�v � fi#,.,. ,(n •�J Y+'�"• .�",'. ikca r ..arr X s5'. �.. ' � .f .F '� � ice. ' �+'"y. {� s"f Y G:;:. '1 F ��'1 '2 �r: j'` '.. q-„�. a ` {v , _, '.� 7 - i DAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION *NOTE: Issued in Compliance With Article 11 of G.S. Chapter 130a -- nitary Sewa§e $ystems, !' Permit Number U t« t ,s �-� . �; � �. _ w � - ► � 13 No 716 Name Date 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 ❑ NO r-1Specificationstor S stem Auto Dish Washer YES NO [� Auto Wash Ma :hive YES NO ❑ x '' t 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. 1 _I 1: 1. n �7 r r , .�, �� "ice/\\.1��.3a- �� � �•-�}.� :�%i 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 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 Environmental Health Section P. O. Box 665 Mocksville, NC 27028 1. Application/Permit Requested By. �O/11fif Z�• fern© w Mailing Address ft / AN( 333 /% )-%LO; 9 Home Phone 5-�VX "' %�� 7 Business Phone 2. Name on Permit if Different than Above 3. Application/Permit for: 4. System to Serve: ❑ Business ❑ House ❑ Industry 5. If house, mobile home: Subdivision No. of People No. of Bedrooms -3 ❑ General Evaluation R nnobile Home ❑ Other No. of Bathrooms ;Z" Dwelling Dimensions A/ X 719 6. If business, industry, place of public assembly, other: Specify type No. of People Served No. of Commodes No. of Lavatories No. of Sinks No. of Urinals No. of Water Coolers No. of Showers Water Usage Figures _ 7. Type of water supply: ❑ Public Private 8. Property Dimensions 3 lyGreS Sewage Disposal Contractor 93 Septic Tank Installation ❑ Place of Public Assembly ❑ Unknown Section Lot # ❑ Basement/Plumbing ❑�Basement/No Plumbing 2 Washing Machine ❑ Dishwasher ❑ Garbage Disposal 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes Ergo If yes, what type? ❑ 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: Inc ct S vi'C L -P a � U , 4 D a - This is to certify that the information provided is correct to the best of my knowledge, and 1 understand I am responsible for all charges incurred from this application. DATE 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 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. s-�3- Y7 DATE SIGNATURE DCHD (12-90) • • ' DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation NAME 2 $ZSS ADDRESS 5 �' PROPOSED FACIILTY DATE EVALUATED PROPERTY SIZE -Q LOCATION OF SITE 6 y W q& Water Supply: On -Site Well Community Public Evaluation B}�.(�L. Auger Boring ✓ Pit Cut FACTORS 1 2 3 4 Landscape position S S Slope % d' O HORIZON I DEPTH `� `' b `' Texture group C L L C L CL Consistence 'F� FZ FT Structure 6V_ 6 `Z Mineralogy 1',) 1 HORIZON II DEPTH LP t' u2 ' t{Z' lye `- Texture groupCIL Consistence Structure Ce C V11 l3 Mineralogy) '• 1 ', HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS 3-5 RESTRICTIVE HORIZON — r- ^ SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE 1 SITE CLASSIFICATION: S EVALUATED BY: • `""i - Qom. a. �' OY'HER(S) PRESENT: LONG-TERM ACCEPTANCE RATE:\ REMARKS: 'Q'� C9�_ \• ' 9"., 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 -Firth VFI-Very firm EFI-Extremely fine 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