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1733 Peoples Creek Rd Lot 1 APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT 1 x Davie County Health Department Environmental Health Section c P.O..Box 665 DMocksville, NC 27028 1. Application/Permit Requested By 7i�Mailing Address 3 % Home Phone Business Phone 2. Name on Permit if Different than Above V10 f�k► ©�' - 3. Application/Permit for: ieGeneral Evaluation ❑ Septic Tank Installation 4. System to Serve: mouse ❑ Mobile Home O Place of Public Assembly ❑ Business ❑ Industry ❑ Other ❑ Unknown 5. If house, mobile home:Subdivision �I f}r G� reYn:� 1' ra�S Section Lot # ❑ Basement/Plumbing No.of People O Basement/No Plumbing No.of Bedrooms '7" ❑ Washing Machine No.of Bathrooms ❑ Dishwasher Dwelling Dimensions ❑ Garbage Disposal 6. If business, Industry,place of public assembly, other: Specify type No.of People Served No. of Sinks No.of Commodes No.of Urinals No.of Lavatories No.of Water Coolers No.of Showers Water Usage Figures 7. Type of water supply: 23'Public ❑ Private ❑ Community 8. Property Dimensions Sewage Disposal Contractor 9. Do you anticipate additionslexpansion of the facility this sytem is Intended to serve? ❑ Yes ®'No If yes,whit type? '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: 1 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. _ H— �S DATE SIGNATURE QQmji FSB mm EVALUATION IQ BE 12=4N ABOVE DESCRIBED PROPERTY MUST CHECK ONE: ❑ 1. 1 OWN the property. �. I 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�Qunty ealth Department to enter upon above described SIC- property located In Davie County and owned by I�J�ri, M� �/2 �y to conduct all testing procedures as necessary to determine said site's suitability for a ground absorption sewage treatment and disposal system. 1�1—��—�vr . DATE SIGNAT E OL ncrw t+i•oo► 104 DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation ate' NAME !�f3 -S DATE EVALUATED �� ST ADDRESS PROPERTY SIZE PROPOSED FACIILTY / Yfl4Lrtf LOCATION OF SITE l��A✓lLu /ICG Water Supply: On-Site Well _ Community Public L� Evaluation By: Auger Boringy _ Pit Cut FACTORS 1 2 3 4 Landscape position L—Slope HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH Texture group e— C' Consistence Structure i0h e Al,k Mineralogy HORIZON III DEPTH 01 Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION S LONG-TERM ACCEPTANCE RATE o SITE CLASSIFICATION: EVALUATED BY: 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 :lay loam- SIL-Silty loam CL-Clay loam SCL-Sandy clay loam SC-Sandy clay SIC-Silty clay C-Clay CONSISTENCE Moist VFR-Vis.-y 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(01-901 ..■............................................................... .................................................................. ■...........■...■..■...../......./..//..■ //■ ■ ■ ■■■ ■.■.■■ ■■ ■ ■■■■■■.■.■.■.■■■■■..■■.■■■■■.■■..■■■.■.■■�' ■■■_ ■'MI_■■■' ■■■■■■■M No ■■/.■.■../■■.■■■./...■../.■■mm■/.■ma■./..■...... 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INM' ... . .........ENE■■ am ■■IN .. ■■MME■IN■MEM■MEN■ ■.MEE M■■EN MEEMMMEMMEMEMM . .. am mom .MEMO NEEM■NEN■ .......Nm■IN...MINMEME■M■MMM.MM.■�Nam�MIN■Na■M.■NM.INNIN.INN.IN.IN..INm■ .................................................................. ...................................■■.0■.■■■.m■m■■H■mm■.mm■m■mm■ MEMEMEMEM OXEN 0 Ir ! r Cb ,, r sLsFl- 3'z- -- . •�,=-� d �/1% t� �i!+-IBJ � - ��. !( � , �. ✓ J L Q11 ``L 46 4• _ /;gam-. - _ �Sfl• t�� I •s p flE S 2sjr S-ba.N Daiie County ✓�lealtFr Deparlment and Nome Nealtf Ayency 210 HOSPITAL STREET I P.O. BOX 665 MOCKSVILLE.N.C. 27028 PHONE:(704)634-5985 June 30, 1995 Gray A. Potts c/o Hubbard Realty 5342 Hwy 158, Suite 1 Advance, HC 27006 Re: Site Evaluation March Ferry Acres-Lot 1 Dear Mr. Potts: As requested, a representative from this office visited the aforementioned site on June 26, 1995. Based upon 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. If you have any questions, please feel free to contact this office. Sincerely, Robert B. Hall, Jr. , R.S. Environmental Health Section RH/wd. Enclosure(s) '9 'i 'vii