155 Abbey Ln , �". '
• ', • DAVIE COUNTY ENVIRONMENTAL HEALTH
P.O.Box 848/210 Hospital Street
Mocksville,NC 27028
(336)751-8760 Fax#(336)751-8786
OPERATION PERMIT
t'�cc�ur�t �: 990005380 �'��x P€�I.�EH#: 5843-35-5185
BiElsd TU: Jonathan Rogers SuE��iivi�ic�t� Ir�To:
R�fer��E�c� �lar3�e: Lacc�lioni�cicir�:��s: 155 Abbey Lane-27028
f�ro�osPd Facility: Residence �ro�er�y Siz�: 3.196 Acres
,�T'C t�uE�b�r: 5004
**NOTE**The issuance of this Operation Permit shall indicate the system described on the ATC has been installed
in compliance with Article 11 of G.S.Chapter 130A,Section.1900"Sewage Treatment and Disposal Systems,"
but shall in NO WAY be taken as a guarantee that the system 'll function satisfactorily for any given period of
time. C�� �- / Q ��
S stem T e: �� a� `� �3 � s�� �
y yp �� � S.T.Manufacturer Tank Date Tank Size_�
Pump Tank Size
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SystemInstalledBy: � �a1 � � E.H.Specialist: � �ate: /� ��J''�� /
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DCHD 11/06 Revised �
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� � DAVIE COUNTY ENVIRONMENTAL HEALTH
• � P.O.Box 848/210 Hospital Street
Mocksville,NC 27028 ����
, (336)751-8760 Fax#(336)751-8786
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
. �,
f'�ccnur�t #: 990005380 �'�x PE�€.�EH#: 5843-35-5185
BEII�;d �'c�: Jonathan Rogers Suk��iuisEur� Ir�fa:
f��;�er�tE3c� P�ar3�E�: Lc�c�tiorir,�c�r�r��ss: 155 Abbey Lane-27028
„
k�ropas�;ci Fa�i€ity: Residence Pro�er�y Siz�: 3.196 Acres
,�TC t�lUt�b+�r: 5004 Site Type: �w ❑Repair ❑Expansion
**NOTE**This Authorization to Construct(ATC)MUST BE ISSUED by the I)av�e County Environmental
Health Section prior to issuance of any building pemut(s), (in compliance with Article 11 of G.S.Chapter 130A
Wastewater Systems, Section.1900 Sewage Treatment and Disposal Systems). THIS AUTHORIZATION TO
CONSTRUCT IS VALID FOR A PERIOD OF FIVE YEARS. This ATC is subject to revocation if site plans,plat
or the intended use change. •
Residential Specifications: #Bedrooms � #Bathrooms� #People�-- Basement� Basement plumbing❑
Non-Residential Specifications: Facility Type #People #Seats
Square Footage(or Dimensions of Facility)
Lot Size . `� ¢0�� Type of Water Supply: ounty/City �Well ❑Community Well
System Specifications: Design Wastewater Flow(GPD) ��� Tank Size ����GAL.Pump Tank�GAL.
�, `� �� L � .
Trench Width 3 G Max.Trench Depth 3G Rock Depth �� Linear Ft. �3�
Site Modifications/Conditions/Other: AS st��eei in 1;iA �!ClIC 18;�.1�f�?(5�
. 3ee����d-�v�,T�T�� rnav a�o c used -
Contact the Davie County Environmental Health Section for final inspection of this system between
8:30-9:30a.m.on the da of installation. Tele hone# 336 751-8760.
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Environmental Health Specialist Date: / � / ` rd �
DCHD 11/06(Revised)
APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC
Davie County Environmental Health
P.O.Box 848/210 Hospital Street
Mocksville,NC 27028
" (336)751-8760/Fax 336)751-8786
Application For: ❑ Site Evaluation/Improvement Permit Authorization To Construct(ATC) ❑ Both
Type of Application: ❑New Sy�tem ❑Repair to Existing System ❑Expansion/Modification of Existing System or Facility
***IMPORTAN7***THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED
INFORII�IATION`IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
APPLICANT INFORMATION
� �ON�t�1a n)
Name to be Billed c�13 y� �1 C Contact Person
Bilfing Address Home Phone
City/Sta�e/ZIP f'}C�yl�Ni:G' �/C- �700G Business Phone 0 . - 723
�
Name on Permit/ATC if Different than Above �
Mailing Address City/State/Zip
��'S�
PROPERTY INFORMATION *Date House/Facility Corners Flagged U (�0 g �,� ,(�
NOTE: A survey plat or site plan must accompany this application. Included: ❑ Site Plan ❑Plat(to scale)
(Pernut is valid for 60 months with site plan,no expiration with complete plat.)
Owner's Name��/�,-�{1Q�I��� �� �'�Pj�S Phone Number
Owner's Address � City/State/Zip
Property Address �'�_ �/ fl�1 City
Lot Size__3��(� � Tax PIN# �$t��-�S/�5
Subdivision Name(if applicable) ect'on/Lot#
Dir ctions To Site: Q ,, % �' ��" p��
I the answe to any of the following questions is"yes",supporting documentation must be attached.
Are there any existing wastewater systems on the site? ❑Yes �
Does the site contain jurisdictional wetlands? ❑Yes �
Are there any easements or right-of-ways on the site? ❑Yes �
Is the site subject to approval by another public agency? �Yes ��
Will wastewater other than domestic sewage be generated? ❑Yes C�2�
IF RESIDE E FILL OUT THE BOX BELOW
#People #Bedrooms �_ #Bathrooms Garden Tub/Whirlpool DYes �No
Basement: ❑Yes ❑No Basement Plumbing: ❑Yes ❑No .
IF NON-RESIDENCE FILL OUT THE BOX BELOW
Type of FacilityBusiness Total Square Footage of Building #People
#Sinks #Commodes #Showers #Urinals
Estimated Water Usage(gallons per day) (Attach documentation of similar facility water consumption)
FOODSERVICE ONLY: #Seats
Type system requested:.�Conventional ❑Accepted ❑Innovative ❑Alternative ❑Other
Water Supply Type:�County/City Water ❑New Well ❑Existing Well ❑ Community Well
Do you anticipate additions or expansions of the facility this system is intended to serve? B'Yes ❑ No
If yes,what type?
This is to certify that the information provided on this application is true and correct to the best of my knowledge. I understand that
any pernut(s)or ATC(s)issued hereafter are subject to suspension or revocation if the site is altered,the intended use changes,or if
the information submitted in this application is falsified or changed. I hereby grant right of entry to the Authorized Representative
of the Davie County Health Deparhnent to conduct necessary inspections to deternune compliance with applicable laws and rules.
I understand that I am responsible for the proper identification and labeling of property lines and corners and locating and flagging
or staking the house/facility location,proposed well location and the location of any other amenities.
— ���r� d�"' ' �Q — Site Revisit Charge
Props etty owner's or owner's legal representative signahue
Date(s):
�d��p-�9 Client Notification Date:
Date EHS:
Sign given ❑Yes ❑No Account# ��
Revised 11/06 Invoice#
} Davie County Environmental Health
. .
, Y ' P.O.Box 848/210 Hospital Street
Mocksville,NC 27028
(336 1-876IIT�F'ax�336j751=8786..,�
,r�� �IMPROVEMENT PERMIT �
�''—�-_._.._..._____..._..._---�-_----�"
Account #: 990005099 Tax PIN/EH#: 5843-35-5185/Site 2
Billed To: Mary Zimmerman Subdivision Info:
Address: 240 Manhattan Lane Location/Address: Abbey Lane-27028
City: Advance Property Size: 6.47
Reference Name:
Proposed Facility: Residence
**NOTE**This Improvement Permit DOES NOT authorize the construction of a wastewater system. An
Authorization To Construct a wastewater system must be obtained from this office prior to the
construction/installation of a wastewater system or the issuance of a building permit(in compliance with
Article 11 of G.S. Chapter 130A,Wastewater Systems). This Improvement Permit is subject to
revocation if site plans,plat or the intended use change.
Pemut Type: fl�1ew ❑Repair ❑Expansion Pernut Valid for: E�Years ❑No Expiration
Residential Specifications: #Bedrooms �j #Bathrooms_�#People�Basement❑ Basement plumbing❑
Non-Residential Specifications: Facility Type #People #Seats
Square Footage(or Dimensions of Facility)
Design Flow(GPD):�(� Type of Water Supply: B�ounty/City ❑Well ❑Community Well
,i��:u�t;d iri 15�. NCAG 1.�A.1�S��a�
Site Modificadons/Pernut Conditions: �,;�.�.�,�;�.i Sy�t�m� m�•�� ;:!:�� he usE
S stem T e LTAR
Initial �C.0 E'�D .2 �j
Re air cG e i n D,2�'S
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Site Plan
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Environmental Health Specialist `�-� Date jn' Z.5 -Q�
i.p.11-06
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.�,�,(`(��� � ATI � R .��ITE EVALUATION/iMF'ROVEMENT PERMIT �, ATC ��
� "> v Davie Counfy�nvironmentail HeaIth
� ' " 3 `���� P.O.Box 848/210 Hospital ;�itreet
�l � Mocksville,NC 270Z��
���' �,.��� (336)751-8760/Fax (336)75:1-8786
'�}i�3iQ ation Fqi: �.�Site Evaluation/Itnpi,�vemeut Permit G Autl�orization To C;onsU'uct(ATC) I:: L3oth
, 'ype o�',9,�����,ation: �]New System ❑Repair to Existing System OExpan�;ion/Modification of Existinr�Systcm or Facility
�•� �,,..
**IASPO rVT***THIS APPLICA7'[ON C,4NNOT BF PROCESSED U1��:LESS AJ.L OP THE REQUIRED
AT10N IS PROVIDED. ]:ef.:r to tl�e INFORMATION B[II.i.ETI:`J for instructions.
APPLICANT INFORMATION
Name to be Billed� Cri w� Contsict Person ��� J�k�'�
Billing Address ` H<�me Phone D
Gity/Statc/ZIP (fnL.I f� � . ��1z��i Busii�ess Phone �3�-Q7Q$--�►$l)3
� C�e<I -qo9•�10�
:` Name on PcrmidATC if DiJjerent tha�i Above
� Mailing Address Ci.ry/State/Zip
PROPERTY INFORMATION *Date House/::�acili Corners Flagged
'�` NOTE: A stuvey plat or site plan must:�ecompany this application. Includ�:ed: O Site Plan ❑Plat(to scale)
(Permit is'valid for 60 month:.w :h site plan,no expiration�vith complete plat.)
Owner's Name flOUF,1q5 N-C.O�JG��. Phone NuinLier��'(,76C�'��9
O�vner's Adctress aiN ���.;y L�{' N� Cii:,�/State/Zip Mt�Ks�rf� - ��/C),-�$ --�J�,
Property Address l70 Ap,1gL�po.�� Cit:; I"11C1C,IE5vi��st.
Lot Size �,y`��}GizE �-T Tax P1N# 5���:33SSIAS ��/
Subdivision Na�ne(ifappIicable)__ Secti•:�n/Lot# d-/7� �
Directions To Site: �D�_�� �o �To�_ N�d_Koao , Rt oN P.+��vrlle Ro, R+�� AgB��I LANE .
If the ans�ver to a�iy of the following qiiesi.ons is"yes",supporting documentati�� must be attached.
Are thcre any e�.isting wastewater systems on Yhe site? ❑Yes I:'f�o
Does tl�c site contain jurisdiciior�al wetlands? O�s f.s�rf�o
Are there an_y easements or ri�ht-of-ways on the site? CIYes f.:�
Is the site subject to approval by another public agency? ❑Yes L�1�I�
Will�vastewatcr olher than dome�•tic sewage be generated'? ❑Yes I:- o
iF IZ�SIDENCE FILL OUT THE f30X BEL�W
'�People #Bedre�or.is #Bathrooms Garden Tub/Whirlpool es I�No
F3aseinent: ❑Xcs No Base�ne:it Plumbing: u'Yes "�Vo
��I�'ON-T2ESIDENC� FILL O1JT THE BOX BELOW
Type of Facility/Business _. Total Square Foota�c: of Building #People
#Sinks #Commodes_ #Showers�. #Urinals
Estimated Water Usage(gallnn�pe,-d��y) (Atiach docum,rnYation of similar facility �vdLer constimption)
FOODSERVICE ONLY: #Seats
Type system rcquesied:. L-^i'C;onventional I]Accepted UI[viovalive qAlternacive ❑Uther_.
Water Supply Type: f�County/City Water LJ New Well OExistin[;Well ❑ Comnuuiity Well
Do you anticipate additions or expansions .�f tl�e facility this system is intended :•�serve? U Yes �o .
Tf yes, what type? i _._ _
This is to cectify that tl�e information provi.led on this application is true and co�rec[to the best of my knowledgc. I understand thar
any perniit(s)or A"1'C(s) issued l�ereafter ai e subject to suspension or revocation.if the site is altered, the intended use changcs,or if
the information suhmitled in tl�is applic:itic:z is fa]siFed or changed. I hereby gr:int rigl�t of entry to the Authorized Representative
of die Davie County Health Departnient to conduct necessary inspections to deteiznine conzpliance�viQ�applicable Iaws and rules.
I understand that I am responsible for the Froper identification and labeling of property lines and corners and Iocating and flagging
or staking the house/ ility lor�ation,propnsed well location and tI�e Iocation of any othcr amenities.
µ�� Site Revisit Charge
roperty o� ez's wner's legal represen rative signah�re
Date{s):
��� /�•- D� Client Noti£cation Date: ___
�'� �
Date � • EHS:
5`�e � �-f� _ ��,
Sign given I IYes flNo Accuunt If � � _
Revised 11/06 Invoice# /
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This instrumem was preparcd�y: JeC1111�eI'_U. Bro�lc, BROS'K & BOCK� P_A.,� P_ h. 13nx 'iG7� Mocksville. NC 27[
QU 17CLAIM DEED—QD-1 Printed and for sale by)ames Williams&Co-,Inc.,f'.O.Box 127,Yadkinville,N,C.27055
STATE OF NORTH CAROLINA, nav�e County. '
7HISDEEU,Madeandenteredintothis dayv( SeptemUer ,19��.,byandbetween
D�' hi� i{ee ('�!ri`i.�l�
of County and$tate of North Carolina,hereina(ter called Grantar,and
_ �ouQJ.as HuglLSouncil _
of n��i P Coun[y and Slate of Norlh Carolina,hereina(ter called Grantee,whose pertnanent mdiling address
;s Rt 5,.�ox i29-1, Morksvil]P, N� 17n1A ,
WIl'NESSETH: ,
�
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NO TAXABLE CONSIDERAt10N STATED � �
u�.:.:.�1.'1�-9�...._:._ .�''/�a.l,G...____.
�......�.�.. .. :. ,.,
� Thal said Grantor, for and in considerollon of the sum o( Ten Uollars (510A0) lo him in hand paid, lhe receipt of which is hereby
acknuwledged, has remised and released and by thesepresents does remise, release, convey, anJ forever quitclaim unlo the Crantee,his heits
andfor succeswrs and assigns, all right, title, claim ant� interest o(the Granlor in and to a certain lot or parcel o( land lying and being in
Farmin�Con Township, bavie Counry,North Carolina,
and more particulariy descriUed as(ollows:
11tACT ON�:
B�GINNING at an iron stake in the line of T. T. Lawtence, SoutheasC corner of the
wikhin:descriUed tract and Northeast corner of Douglas H. Counci.l 4.00 acre tract
! and running thencs with Council line North 83 degs. 16 min. West 172.53 feet to an
I iron in the line of B. C. 13rock, Jr.; thence with Brock lin� North 07 degs. 16 min.
East 532.07 feeC ta an iron in Che Svuthern right of way margin of SR 1431 (commonly
knowxt as Pineville Ftoad); thence with the Southern right of way margin o£ said SR
1431 the following 2 courses and distances: South 39 degs. 15 min. East 119.38
fee[, South 31 degs. 09 min. East 130.62 feet to an .iron, Nortliwest coxner o£ T. T.
I,awrence; thence with Lawrence line South 06 degs. 27 min. 25 sec. West 344.99 feet
TO THE POINT AND PLAC� OF BEGINNING, containing 1.79 acres, more or less, and be�n�
� a portion of thoae lands described by deed recorded in Ueed Book 115, page 527,
Davie County Registry. Tkte above lands are subject to a1.1 easements, reservaCions
and restricCions of record and particularly [o any easements af ingress and egress
lieretofore conveyed to Aouglas Ilugh Council and wife, Debbie Lee Council.
TRACT 7'W0:
BEGINNING at a new iran, the Northeast corner of Che within described tzact in the
line vf I'rank McClaurin (DB.63, p. 286) new corner of J. K. Miller; said iron pin
being locaCed Soutt► 06 degrees k4 minutes West 761.45 feet from a concrete monument
found in the Miller - McClaurin line; thence from the beg�.nning South 06 degreea 44 �
minuCes West 761.45 feeC to an axle, the SouthwesC corner of Frattk MCClaurin,
Northwest corner of William F. Brock, 5r. (DB 100, p. 250); ttience Sout11 05 degxees
55 minutes 54 seconds WesC 376.16 Peet to an iron pin, the SouCheasCern corner of
the wittiin described tract; thence NorCh 86 degrees 23 minutes 50 seconds West
200.58 feeC to an iron pin, the 5outhwest corner of the within described Cract,
5outheastern corner of B. C. Brock, Jr.; L•l�ence with the line of B. C. Brock, Jr..
North 07 degrees 16 minutes East 1�148.58 feet to a new iron pin, tlie Northwestern
corner of the withln described tract, new Southwestern corner of J. K. Miller; �
thence Svuth 83 degrees 16 minutes East 184.34 feet TO TEIG POINT AND PLACE OF
BEGINNING, containing 5.00 acres as surveyed by C. Ray Cates, March 1, 1983.
TOGE�HER WITH A NONEXCLUSIV� EASEMENT for purpose� of ingress, sgress and regress;
sxid easemenk being 30 feet in widttt, Che Tiastern boundary running from the
beginning point of the above described 5.00 acre tract NorCh U6 degrees 44 minutes
East 401.58 £eet to a concrete monument; thence Nortih 06 degrees 27 minutes 25
seconds East 916.79 ieeC to an iron pin, being Che Northeastern corner of J. K.
Miller described in Deed Iiook 115, page 527, and being further located in the
Southern righC of w�y margin of 5R 1G31.
� To have and to I�old the aforesaid lot or �ar�el of land and all rivile es thereunto belon in to him,the Grantee,his heirs and/or successors
I P B b 8
and assigns, (ree and discharged from all right,title,Glain���r inter�st of thc Grar.tqr or an)rone dd�ming by,through or under him.
The designalion Grantor and Grarnee as used herein sliall include said parties,their heirs,successors,and assigns,anJ shall include singular,
plural, masculine, feminine or neuter as required by context. •
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11V WITNESS WNEREOF,the Grantor has hereunlo set his hand and seal,or if corpora�e has caused lhis insirument ta be signecJ in its corporate
� � name by its duly authprized o(ficers and its seal lo be hereunto af(ixed by autliority of its Board of Directors,the day and year first above written.
.
�1 IIJ. � J /�o//�I I ISEAL)
� � (Curporatc Name)
gy President (SEAU
ATTES7: 5ecretary ... ,r_ (SEAL)
(Corporate 5eal) (SEAL)
SEAL-STAMP NORTH CnRULINA,_ ngy�e. CUUNTY.
1,a Notary Public of the County and State aforesaid,certify that R�hi�...Y.e�liilcil �
A06�T�.MISBECK bl
eoranr rue�x
personally appeared before me this day and acknowledged the execution of the oregoing instrument. Witness my
Fonsrni cca�n Rh�.
hand and offitial stamp or seal,this �day of OC 6� ,�q 93 .
MyCommission expires: �-7��/,$' Notary Public
SEAI-STAMP NORTH CAROUNA, COUNTY.
I,a Notary Public of lhe County and Stale aforesaid,certify that
Trustee,
personally appeared before me Ihis day and acknowledged the execution o(the foregoing instrument.Witness my
' hand and officfal stamp or seal,this day o( ,�9 ,
My Commission expires: �Notary Puhlic
i
I
SEAL-STAMP NORTH CAROLINA, COUNTY,
1,a Nolary Public of the Countyand State dforesaid,certify thal ,
personally came be(ore me this day and acknowledged ihat____he is—. Secretary of
a Nc>rlh Car��lina corporation,and that by auth�rity �
duly given and as the act of Ihe cor�x�ration,Ihe foregoin�,instrumenl was signed in Its name by its_... ..
President,sealed with its corpora�e seal and attested by _ as its _Secretary.
Witness my hand and official stamp ur seal,this_ day of ._ . ,19 �
My commission expires; Notary Publ�c
The foregoing Certificate(�o( R�'� H. Raisbec}C, J�. Notaxx PubJ ic ,
_ of_ Fors�hl�► Caunty
1sQmms�certi(ied to be correct.This instrument and this cenificate a�re duly registered this_2Z-�day aF ,.,7anti� ,�g 94 "
at���A.M.;�st, 600k 172 ,Page '�Rl ,
�`mY Ii�SH�3Fi Register of Deeds tor DAVIE County,Nonh Carolina.
By �L�d.(I r �• ��G��Ij�a ._��}�f$�rlAssistant—Register of Deeds.
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� , . - DAVIE COUNTY HEALTH DEPARTMENT
^ Environmental Health Section
Soil/Site Evaluation �i���'
aPPL�'c9d�'�'tI�F6�@6C�N Tax PIN/EH#: 584��j�����pRMATION
Billed To: Mary Zimmerman Subdivision Info:
Reference Name: Location/Address: Abbey Lane-27028
Proposed Facility: Residence Property Size: 6.47 Date Evaluated: �� ��� � �
Water Supply: ' On-Site Well ' Community Public _�_
Evaluation By: Auger Boring Pit Cut
FACTORS 1 2 3 4 5 6 7
Landscape position 1— � •
Slope %
HORIZON I DEPTH � -= �(6
Texture grou $'. L' 3'; � 'L
Consistence �� ,r
Structure 5 K /C L
Mineralo � Y -- Sr 5'F-
HORIZON II DEPTH
Texture rou � �
Consistence
Structure
Mineralo
HORIZON III DEPTH
Texture rou
Consistence
Structure
Mineralo �
HORIZON IV DEPTH
Texture rou
Consistence
Structure �
Mineralo
SOIL WETNESS
RESTRICTIVE HORIZON / �'
SAPROLITE � i' /
CLASSIFICATION 5
LONG-TERM ACCEPTANCE RATE � � 7
SITE CLASSIFICATION: � EVALUATION BY: ��"VC2 1�0� �
LONG-TERM ACCEPTANCE RATE:Q. �� �_ OTHER(S)PRESENT: r���N r C� �
REMARKS: " �� �� � C �
LEGEND
i,andscape Pasition .
R-Ridge S -Shoulder L-Linear slope FS -Foot slope N-Nose slope
CC-Concave slope CV-Convex slope T-Terrace FP-F1ood plain H-Head slope
T�xtur� .
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
.ONr SIS�F1�1 .�F.
Moist
VFR-Very friable FR-Friable FI-Firm VFI-Very firm EFI-Extremely firm
}�
NS -Non sticky SS -Slightly sticky S -Sticky VS -Very Sticky
NP- Non plastic SP- Slightly plastic P-Plastic VP-Very plastic
Str�cture
SC-Single grain M-Massive CR-Crumb GR-Granular ABK-Angular blocky
SBK-Subangular blocky PL-Platy PR-Prismatic
Mineralo�v "
1:1,2:1,Mixed
LYotes
Horizon depth-In inches
Depth of fill-In inches
Res[rictive horizon-Thickness and inches from land surface
Saprolite-S(suitable),U(unsuitable)
Soil wemess -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 DCHn(15/(15 (Revice.�l