Academy Place Lot 2 (2) �-� APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT&A [E 0 V E
• Davie County Health Department
Environmental Health Section
P.O. Box 848 MAY— 3 2000
Mocksville,NC 27028
(704)634-8760
****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSED UNLESS
ALL THE REQUIRED INFORMATION IS PROVIDED.
1. Name to be Billed 1 b-\ Contact Person akkkT, C Nkk-L--
Mailing Address /3 �'� 2 e e.�.� ` �cl�. Home Phone
Y p
Cit /State/Zi Business Phone
2. Name on Permit/ATC if Different than Above
Mailing Address City/State/Zip
3. Application For: Site Evaluation ❑ Improvement Permit&ATC ❑ Both
4. System to Serve: a�ouse ❑ Mobile Home ❑ Business ❑ Industry ❑ Other
5. If Residence: # People # Bedrooms 3 # Bathrooms �--
❑ Dishwasher ❑ Garbage Disposal ❑ Washing Machine ❑ Basement/Plumbing ❑ Basement/No Plumbing
6. If Business/Other: Specify type # People # Sinks
# Commodes # Showers # Urinals # Water Coolers
If Foodservice: # Seats Estimated Water Usage(gall�onss per day)
7. Type of water supply: ElCounty/City l7 Well ❑ Community
8. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes ❑ No
If yes,what type?
PROPERTY INFORMATION REQUIRED: ***IMPORTANT***A PLAT OF THE PROPERTY MUST BE
S✓bTJBMITTED WITH THIS APPLICATION.
Property Dimensions: /lo K r3 3,5 y W y L16 3 �u2`�e WRITE DIRECTIONS(from
G2� Mocksville)TO PROPERTY:
Tax Office PIN: # .�� � � - �� - G1
Property Address: Road Name �eOc
City/Zip Ak r kG s-,\q,12- N C-
1 2
If in Subdivision provide information,as follows: 1
Name: C. P'P0>V!V'SG
1
Section: Lot #: 1
This is to certify that the information provided is correct to the best of my knowledge. I understand that any permit(s)issued hereafter
are subject to suspension or revocation,if the site plans or intended use change,or if the information submitted in this application is
falsified or changed. I,also,understand that I am responsible for all charges incurred from this application. 1,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 \o a�'� to conduct all testing procedures
as necessary to determine the site suitability.
DATE i� CT SIGNATURE ha
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This map is for PERC TEST
r and BUILDING PERMIT purposes
N only. The Davie County
e Tax Administrator's Office
assumes no liability for any
information contained on this map
ts�
(385)
COUNTY-ID:K200000060
6879
February 02,2000 4:28 PM
RnC
Parcel Identification Number
5717-40-0795
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
APPLICANT INFORMATION PROPERTY INFORMATION
Account #: 989900113 Tax PIN/EH M 5717-07-4137.02
Billed To: Floyd Green Subdivision Info: Academy Place Lot#2
Reference Name: Mackie McDaniel Location/Address: Davie Academy Road-27028
Proposed Facility: Residence Property Size: 3.96 Acres 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 1-1
Slope%
HORIZON I DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH (o ' l
Texture groupG'
Consistence r
Structure
Mineralogy
HORIZON III DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE
SITE CLASSIFICATION: N EVALUATION BY: - G
LONG-TERM ACCEPTANCE RATE: / OTHER(S)PRESENT:
REMARKS:
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)