Ashley Lane, Lot 4 .+rr.,titasuw tuts atlt tvAMAHON/IMPROVEMENT PEIIMII do AIC r ---
` Davie County Health Department
Env1ivnmenfa/Healf�liSecffon
P.O. Box 848/210 Hospital StreetMR F
Mockaville, NC 27028 11999
1336)751-8760
EIJYIRONM
***XMPORTMPZ*s• THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL Nn
INFORMATION IS PROVIDED. Refer to the I/NFORMATION BULLETIN for instructions.
Name to be Billed _ i 142 i+G� �i?464 / � Contact Person � ) l ��L✓r c�p1 ce /-
Mailing Address .D 411 !�/ Boma Phone �2
city/state/21P . Business Phone
t. !lams on Pewit/ATC if Different than Above
Mailing Address City/state/Lip
s. Application For: W Site Evaluation ❑ Improvement Permit/ATC ❑ Both
4. system to service: Douse ❑ Mobile Home ❑ Business 0 Industry ❑ Other
a. If Residence: # People ,�Z _ # Bedrooms 3 # Bathrooms Z
"ishwasher 0 Garbage Disposal (gashing Machine 0 Basement/Plumbing -4hasement/No Plumbing
6. If Business/Industry/other: specify type # People # sinks
# Coamodea # Showers # Urinals # Mater Coolers
IP YOODSERVICE: if Seats Estimated stater Usage (gallons per day)
7. Type of water supply: ❑ County/City eNell ❑ Community
e. Do you anticipate additions or expansions of the facility this system Is Intended to serve? ❑Yes "0
If yes,what type?
***IMPDRTANT*** CLIENTS MUSTCODIPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED
BELOW. Either a PLAT or SITE PLAN MUST BESUB1111TTED by the client with THIS APPLICATION.
J
Property Dimensions: J (,D
c re-5 WRITE DIItEC1'IONS(from MockrAlle)to PROPERTY:
Tax OMce PIN: # ���3�-9i'-S7 7/ ( -oo!fiL) 601 A/ 'fid 69,1,2 Rd T tcl1.
Property Address: Road Name flh S efl Rd, JO f1m, &y' r.,h. R Io,
City/Zip 2 7 o
If in a Subdivision provide information,as follows:
Name: em
Section: Block: Lot: Date Rmperty Flagged: Sy ea- &A buds h e n 4Z;
This is to certify that the information provided Is correct to the best of my knowledge. i understand that any permil(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 nsnonale 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
to conduct all testing procedures as necessary to determine the site suitability.
DATE 3 / fq SIGNATURE
IF
THIS AREA MAY BE USED FOR DRAWING YOUR SITE P (Include all of the following: Existing and proposed
property lines and dimensions, structures, setbacks, and septic locations).
Account No. / O
-7
Revised UCHD(07/98) Invoice No. (o2
33
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/ N N
O O
O
/ 638.08' 271 26
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5 . 023 cres
134.12•
'Acres
tiYL
N 5 . 001 Acres
N
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L4
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5 . 022 Acres
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• •DAVIE COUNTY HEALTH DEPARTMENT
• Environmental Health Section SECTION LOT
Soil/Site Evaluation
APPLICANT'S NAME DATE EVALUATED
PROPOSED FACILITY PROPERTY SIZE
SUBDIVISION ROAD NAME
Water Supply: On-Site Well Community Public
Evaluation By: Auger Boring Pit Cut
FACTORS 1 2 3 4 5 6 7
Landscape position G
Sloe%
HORIZON I DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH
Texture group
Consistence
Structure 1�.t
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: EVALUATION BY:
—o
LONG-TERM ACCEPTANCE RATE: 1,2 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(O1-90)
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