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652 Hwy 801S (2)DAVIE COUNTY HEALTH DEPARTMENT `= 4 IMPROVEMENTS PERMIT AND . CERTIFICATE OF COMPLETION *NOTE:'Issued in Compliance With Article 11 of G.S. Chapter 130a Z2o a% Sanitary Sewage Systems Permit Number Named!' a�Kii�P.ry�'� ��G'ti"��/lg��✓ Date NO Location X5 K " ��11 Yr—r— Subdivision Name Lot No. Sec. or Block No. Lot Size % House 41111' a Mobile Home _� Business Speculation No. Bedrooms / No. Baths _�_ No. in Family _ Garbage Disposal YES ❑ NO Specifications for System: Auto Dish Washer. YES ❑ NO Auto Wash Ma :hiveYES ❑ NO [P �dD�✓% `r� X 2 `� 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. 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 Insta led by y, �0, 1 � 1 - r ..f Certificate of Completion 1l 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 satisfactorilv for anv aiven period of time.. 7F APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT _ Davie County Health Department j' �. i; i;s" !« V: Environmental Health Section>. P. O. Box 665 Mocksville, NC 27028 std By Mailing Address Z '' U. -4-)d�/d X /6 X lfVcJ79 C�-- Home Phone 7'2 �JE ,�,0 0:2, Business Phone. 2. Name on Permit if Different than Above 3. Application/Permit for: ❑ General Evaluation 4. System to Serve: ❑ House ❑ Mobile Home JR Business ❑ Industry ❑ Other 5. If house, mobile home: Subdivision No. of People No. of Bedrooms No. of Bathrooms Dwelling Dimensions 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 Septic Tank Installation ❑ Place of Public Assembly ❑ Unknown Section Lot # ❑ Basement/Plumbing ❑ Basement/No Plumbing ❑ Washing Machine ❑ Dishwasher ❑ Garbage Disposal No. of Showers Water Usage Figures 7. Type of water supply: J$1 Public ❑ Private /J 1 ❑ Community 8. Property Dimensions s Sewage Disposal Contractor 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes Jgl 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: e -' 'O5.5 ipai �/ 0/,7 3s �'I This is to certify that the information provided is correct to the best of my incurred from this application. DATE SIG I understand I am responsible for all charges 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 f erm 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. Z, DATE SfGNATURE DCHD (12-90) i DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation NAME A, J L�L�yG'--, ADDRESS PROPOSED FACIILTY DATE EVALUATED ,--Z' % PROPERTY SIZE LOCATION OF SITE VIII Water Supply: On -Site Well Community Public -L-1 Evaluation By: Auger Boring r,-,' Pit Cut FACTORS 1 2 3 4 Landscape position A. E. 4 L Sloe Z =— — — HORIZON I DEPTH Texture group Consistence Structure MineralogX HORIZON II DEPTH Texture group Consistence 411 Structure r siji� ii 6/C Mineralogy - / HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION J LONG-TERM ACCEPTANCE RATE , SITE CLASSIFICATION: LONG-TERM ACCEPTANCE RATE: REMARKS: DCHD(01-901 EVALUATED BY: A/0 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 -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 Mineralolly 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 ■ON■ ■■M■ ■ME■ ■