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1535 Fork Bixby Rd (2)APPLICATION FOR SITE EVAl1)A11ON/IMPROVEMENT PERMIT &Ili Davie County Health Department U • - •' Envimmental HOW& Sedan P.O. Box 648/210 Hospital Street 001THEALTH Mockaville, He 27028 (336)751-8760 FraviRn ***IWORVJM** THIS APPLICATION CU= BIS PR=SSZD UNLESS ALL VRA It (JUIRBD I2:D'ORHATI0N IS PROVIDED. Refer to the 11NORMATI014 BULLETIN for instructions. 1. dace to be. siUed M 1 Kf %Ata r,4 Z Contact fersoo A& or LeL &, wiling address 1535 ForK 61 1 bV Rd aa.. ftone(330) 99% X244:-_ City/State/a:9 liryahGe— NC, Z%00 (o swsnese chow. Z. lits on Veait/ATC i! Different than Above wiling address Cit:/State/aip a. Application tor: X Site Evaluation 0 Improvement Permit/ATC O Both e. Syetew to services JK House 0 Mobile Home 0 Business 0 Industry 13 Other s. If Residence: ! people ! Bedrooms ! Bathrooms Dishwasher U Garbage Usposal lashing laohUm O Sasesent/Oltsbing 0 sasesiont/No pl=bing 6. !f easiness/Indnatry/Otber: Specify type ! "Via ! sinks ! Coevwdes ! Showers ! Urinals ! later Coolers IF 1`OODSERVICs: # Seats Estimated Water Usage (gailone per day) 7. Typi'ot.water supply: County/City 0 Well 9. Do you anticipate additions or expansions of the facility this system Is intended to serve? If yes, what type? 0 Community O Yes I�No 'IMPORTANT"" CLIENTS MUST CIOMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED ;t: BELOW. Either a PLAT or SITE PLAN MUST IS by the client With TIM APPLICATION. "t.A"- r Property Dimensions: _ WRITE DIRECTIONS (from MockrAlle) to PROPERTY: 5-7-711f06- Tax `77%O6_Tax Office PIN: fl n �° 04 WEST Lnw ar & i f &'nr) 4-0 on Property Address: Road Name I 35 FnrK R 1 �bv F7o r K Ri` 4 Wood, HIn a Subdivision pde Informsdoa, as follows: b1 ib� 7 Name: Section: B ocks Lot: Date Property M aggeds This is to certify that the Iahrmation provided Is correct to the best of my knowledge. I understand that any permit(:) Issued hereafter are subject to suspension or revocation, if the site plans or Intended ase change, or If the information submitted in this application Is fabilled or changed. 1, also, understand that I am responsible for all charges Incurred frons this application. 1, hereby, give consent to the Authorittd Representative of the Di�vIP Com1 Health Dep teat L to enter upon above described property located is Davie County and owned by 111 c li", # I � "VK\JJ l,S''t i to conduct all testing procedure as necessary to determine the site suitability. DATE ��. UK/l o� : oGVDi� SIGNATURE "A THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (Include all of the following: Existing and proposed : ,1 f � e1T'•'7 �' � f.. f fit, .��li!.:i�.3 w'�f�e�l+.?�+��r�S 'A �.:, ��, � .^�•', 'tri �ll ,p i�a4► ;, , ' "Lir ;y .Jii� t t a,. 91MW sxv 3- -Q06 t IVO, f i i ' it '' ,. .. {f �s'r;' , . 0• t ' �� t 1 +, ,, : ,N t�`'t�. a �l • � t � �jr. • • � I.i � i! , , � '� ti � ''t ,. 1 •, , � �T �II'�( .e ! +`' � 'k11t. / f. � �, .L 1 '9�4, lir !, � 'IZA �' '. ii,� r�• 1•.�a,.• y °4 �`, ii, lt; '"1� t '`i.� ti`�91 Q ' ��,, 1 � �"' FI+I • , �• j 'r,,,r,� Qk'r'MJf �•' . 1 �' , 7*hl , F�� - I • a� Jai, . ,i A ?^^"� �i ' .j �.. O. ,,. O N ,A N 0) OQ OB/ 4 r ri 2� a .) "�t'� �P; w� ' / r rii ' `t�;i�'`i�'1': .,,� , '�►". , � : ,, .fig w .. +�j � +i : • � � � '•l � :. -41 V. 86T oil}� t 0 9 ;►"`� , ; � 0�V 9., 31 ' N _8 mo /\SJ` 11 a''w 99 VL '' �,ii It + r1°I. •. ' ' r cri �•� ' " + i:': • { t'9,w VM '��'� zE' 856 ' � _{ �� • �, �z'' FF. 0912 t v .1—A fill tet,' ��,` �1... .P' I � ,�. y0��' •• , ,. � " •tt� � °,.'e jAZ 1;�'► 1t' .,bZ +.� '�V 9'b w '"tr ,ti• . y..i,+� 1 ° ...I a' I ' + ' • a (] J ^A Oe y , j` ll?`J 1 '' it .•ftrM� 1 �7 �' , , / 1 7. Cdvwl °`ji`• • �v a,, ••'f 'a~:,'l.t k+�J . '•'� Yi�.�'' {I pC!!r, l . TU rf ' f t' � 1. '';t� ';C �j � ,'0.V {�6�`''' •��' Vr�i '1' ''< �q` ,l '�' • fit ''k �.!,''l�' r .` ,� t+..r ,�- ft `.'� • � J} . ��`.. 1�� ti ±i:. A YIP {:�.,�� •.'- '�',ty. oil :�. r,�°. ' .�� g691 'a' :t;.,�.";H .'dad j� 6'91 2:1 £, +f' • +! .rte,!; ,;t r l .., ti �'' 0 ' V 9 •, i.:: j� , ',1'? a3V96'ZIColl '•'ter ;; �,t' rr� £4'Z69 + ' i • " �' IC�'`f - .., � • APPLICANT INFORMATION Account #: 990001431 Billed To: Mike Swartz Reference Name: Proposed Facility: Residence Water Supply: Evaluation By: DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation PROPERTY INFORMATION Tax PIN/EH #: 5779-066260 Subdivision Info: Location/Address: 1535 Fork Bixby Ro-27 06 Property Size: see map Date Evaluated: �� CD On -Site Well Community Auger Boring Pit Public Cut FACTORS 1 2 3 1 4 5 6 7 Landscape position Slope % HORIZON I DEPTH— Texture groupG� Consistence SSS rSS�, Structure G2 Mineralogy ,. I . I HORIZON II DEPTH _ vz- Texture groupC Consistence �- Structure L G Mineralogy HORIZON III DEPTH _41 — Texture group C- A4110c Consistence S Structure Mineralogy.1 I - HORIZON IV DEPTH Texture group' Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE 22 SITE CLASSIFICATION: LONG-TERM ACCEPTANCE RATE: 3 REMARKS: EVALUATION BY: 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 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 05/99 (Revised) ■ ■ ■■■■■■■■EMEM■ ■E■■MEM■■EME■ ■E■■E■■■M■■E■ ■EM■■■EMMOM■■ ■EM■■MEM■■E■■ ■■EM■■E■■MM■■ MEMO ■■E■ ■O■■ MEMO ■■■E■EM■■MM■EEM■E■ ■MMMMMM■MMMMMMM■■■ ■■■MMMSMMMMINMMMM■ ■EMME■■MEM■ OMME■■ ■■■■■■■■■■■M■ ■■■■■■■■■■■■■ ■■■■■■■M■■■■■ ■■■■■■■■■■■■■ ■■■■■■■MMM■■■ ■■■■M■■■■M■■■ ■■■■MEEK, ■■■■EMER ■■■MEMS■ ■M■■E■E■ ■OM■■■■■ ■■■■■■■■ ■■M■■■■■ ■■■■NGEMEO■■■■■MM■ ---------■■■■■■■■■ ■■■■■■■■■■■E■■M■■■ ■■■■■■MMM■■■■■■■■■ ■■MM■■■■MPMEMME■E■ ■■■■■■■E■oniMO■■■■ ■■M■■■■■■M■M■■■■■■ ■■■■MMMMMM■■M■■■O■ ■■■■■■■■■■■■■■■■■■ !�\i.111!■■f/J■■■■!fir■■�■ ■■■r■■ ■M■ \■ ■E■■M\\ F' ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ BEENE iMEMEMMMEMEME MEMNON= ■■■■■■■■M■■■■■■ ■■■■SSS■■■■■MM■ ■■MM■■■■■OMM■■■ ■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■ ■■■■■■ ME■M■■ MM■■■■ ■ ■ ■ i ■ ■■■■■■■M■■■ ■M■M■■■■M■■ Davie County Neal th Department Environmental Wealth Section PO Box 848 / 210 Hospital Street Mocksville, NC 27028 Phone: (336)751-8760 October 10, 2000 Mr. Mike Swartz 1535 Fork Bixby Road Advance, NC 27006 Re: Site Evaluation - 1/2 of 1.5 Acre Tract/Fork Bixby Road Tax PIN #: 5779-06-6260 Dear Mr. Swartz: As requested, a representative from this office visited the above site on October 6, 2000. Based on the information provided on the Application for Site Evaluation and after the evaluation was completed, the site was found to be provisionally suitable for the installation of an on-site sewage disposal system. Based on the evaluation, a three-bedroom residence would require approximately 350 linear feet of septic drain line. This is subject to change and actual dimensions of the septic drain field will be determined at the time an improvement permit is issued. Before a representative of this office will revisit the site to issue an Improvement Permit/Authorization to Construct the appropriate application must be completed in full and submitted to this office. The location of the facility the system is to serve must be staked off. If you have any questions, feel free to contact this office at (336)751-8760. Environmental Health Section enc(s) V Davie County Neal th Department Environmental Wealth Section PO Box 848 / 210 Hospital Street Mocksville, NC 27028 Phone: (336)751-8760 October 10, 2000 Mr. Mike Swartz 1535 Fork Bixby Road Advance, NC 27006 Re: Site Evaluation - 1/2 of 1.5 Acre Tract/Fork Bixby Road Tax PIN #: 5779-06-6260 Dear Mr. Swartz: As requested, a representative from this office visited the above site on October 6, 2000. Based on the information provided on the Application for Site Evaluation and after the evaluation was completed, the site was found to be provisionally suitable for the installation of an on-site sewage disposal system. Based on the evaluation, a three-bedroom residence would require approximately 350 linear feet of septic drain line. This is subject to change and actual dimensions of the septic drain field will be determined at the time an improvement permit is issued. Before a representative of this office will revisit the site to issue an Improvement Permit/Authorization to Construct the appropriate application must be completed in full and submitted to this office. The location of the facility the system is to serve must be staked off. If you have any questions, feel free to contact this office at (336)751-8760. Environmental Health Section enc(s) sot [OD sr