742 Fairfield RdDAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTE: Issued in Compliance With Article I I of G.S. Chapter 130a
Sanitary Sewage SystemsPermit Number
..
Name ��� Q Date 1 t ' �� 1 �y ' ND 7.8 05t
Location �(� 5 �-� w LU'c9���wsw`w.
kid-
Subdivi ion Nam Lot No. Sec. or Block No.
1
Lot Size `� House Mobile Home — Business Industry
No. Bedrooms I No. Baths No. in' Family ' Public Assembly Other
Garbage Disposal YES NO a
g p ❑ Specifications for System:
Auto Dish Washer. YES ❑ NO E� b C) U
Auto Wash Ma^pine YES O ❑'"
_... w f 13 y
s
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 T.�
Improvements permit by fir"
f *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 —"�
- � F
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.
']i _ APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PER
Davie County Health Department I' V ED
Environmental Health Section NOV Z�9�
P. O. Box 665
Mocksville, NC 27028
1. Application/Permit Requested'By f 0 r
Mailing Address 7 S /mow u/ Home Phone O
14 v_ 1� iV .(�=^��5!/ ti'� Business Phone
2. Name on Permit if Different than Above
3. Application for: �� ❑ General Evaluation �'� Septic Tank Installation Permit
4. System to Serve: Lid House ❑ Mobile Home ❑ Place of Public Assembly
❑ Business ❑ Industry ❑ Other ❑ Unknown
5. If house, mobile home: Subdivision Section Lot #
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 Showers
7. Type of water supply: ❑ Public
8. Property Dimensions
No. of Sinks
No. of Urinals
No. of Water Coolers
Water Usage Figures
—`,0 Private
Sewage Disposal Contractor
❑ Basement/Plumbing
❑ Basement/No Plumbing
❑ Washing Machine
❑ Dishwasher
❑ Garbage Disposal
9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes `TI No
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: �A JCh. 0 %Yl Lr�,7-tr�.��-c_"DGt"0
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.
9
Pe�*�
DATE SIGNATURE
CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY
MUST CHECK ONE: ~`p 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.
DATE SIGNATURE
DCHD'(1/93)
{ Y�- DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site .Evaluation
NAME
ADDRESS
PROPOSED FACIILTY
DATE EVALUATED - 9 L�
PROPERTY SIZE ?
LOCATION OF SITE
FACTORS
1
2
3
Water Supply:
On -Site Well
Community
Public
Evaluation By:C,-,-L,
Auger Boringy
Pit
Cut
FACTORS
1
2
3
4
Landscape position
__5
__s
--S
Sloe %
- S
F-17-
'I
HORIZON I DEPTH
1 `'
2 `'
Texture group
(Z'4
�-
Consistence
Structure
Mineralogy
HORIZON II DEPTH
Texturegroup
C
Q__c-
Consistence1
_�
Z
S
Structure
'�>Iq_
Mineralogy
HORIZON III DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
.Sf
RESTRICTIVE HORIZON
--
�--
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE
04
SITE CLASSIFICATION:
L,
LONG-TERM ACCEPTANCE RATE: `^ �
REMARKS: �� �l '\'
DCHD(01-901
EVALUATED BY: `
OTHER(S) PRESENT:
. ti
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
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
0