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143 Mortgage Hill Way � . � . � � DAVIE COUNTY ENVIRONMENTAL HEALTH ' ' ' P.O.Box 848/210 Hospital Street � ��``� ' Mocksville,NC 27028 1� (336)753-6780/Fax#(336)753-1680 OPERATION PERMIT Acc+�u�t #: 990001724 Tax�i�€!EH#: 5823-35-7658 Bilie�€ To: Tom Kitchene S��t�i�fi�ic�r� lr���: q (5'7 t�e:��t-�r�ce P�ar��e: LoeaiioniAd�r���: Mortgage Hill Way-27028 f�rapc�s�c9 F,��;ility: Residence �rr���rty S�iz�: 4.9 Acres ATC P��a�tb�r: 5018 **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 will function satisfactorily for any given period of time. System Type:Q� � S.T.Manufacturer ,S' � Tank Date li-9 Tank Size� Pump Tank Size�t/�/�' System Installed By: /�l Bj�'fj�B E.H.Specialist: Date: Z-/7-10 __�-- � �f.9•A� ,�'`� 3a e�a►.b�.. t��e,. �� � �S�c�►a..h�: oo�� � Gtl\ 1+w,,. u�• �,•Lu..l. o i l ?S'�'f � 9 P � v r � � �� � 1 Y a � �r t� � 4�� � F � r , � � Y \� 1 J ( {�('�tS� e�s,�� k'.{� DCHD 11/06(Revised) . r . �Dec 07�03 10:43a Davie County Environmenta 3367518786 p.2 ,� - � U-` 4 � ,1 D:�VIE CUUN7'Y EI�lV1RONMEN1Al.HEALTH V` l'.O. 8�x Sa3�'�)U H�spit�ll S!TL'C: r�� ' Mucksville,�JC 27028 � (336p�3•6180!Fax rr (336)753-i6�U :1UT[lOR(Z�TIO�I.FOR 1VAST�1ti'A1'ER SYS'i'�:M COI�STRG'CTlni�t hccc�unt #: 990001724 Tax P:f�;�H#: 5823-35•7658 C3il3ed To: Tom Kllchene S;1'J�IV1�IVi1 �flfi): ,[�� Re:tei��nce Name: Loc<7iion1.4d�Jress: Morigage Hill Way27028 f�ro�t�sPd Fa�,iliEy: Residence f�rnpe�ly Sizu: 4.9 Acres ,M'CC N��rnb2r: 5018 Sitc Cypc: ;��� DRepair i�Expansion "*NOTL'i This Autiiorization to Construct(A"I'C}MUS7'BC ESSUtiD by the llaric Co��n�y Cnvironmental I Iealtlt Section prior�o issu;�nce of any huilding permit(s),(in cumplianec with Articic 1! ufG.S.Chapter f 30A WsLciewatar Sys�ems,Scction.1900 Sewage Treatment and Disposal�yslems). 'C1IIS AU"I'HORIZATION TA CONSTRUCT lS\�ALID FOR A PERiOD OF F1VE YEARS. T6is A'tC is subject tu revueation if sile ptans,plat or the inteoded use change. Itesidential Specifications: K'Hedraoms_��Bathrcoms�- fl Ycopte �Basement�� 13asemenl plumbing:7 Nan-Resi�3ential Specit'ications: Focility Type,, rt Pcople. T�Seats Squarc Footage�or Dimensions of Faciliq�)__ Lot Size "I � /d�'�g Type of W1ttr Sttpply: eunty/City �:Wel) OCornmunity\�V�II o� pv System Specificalions: D�sign Vr'astewa�cr Flow(aPp) �G�ank Sizc ��� GAL.Pump 7'ank ri r GAL. ti� _� I� �' f�� . Tre�ich WidEh 3� �tax.Trench Depth ,,G Rock I�eptl�_� Linear Ft. �� e o i �ca�ons, on ��ons� �cr:__.. , ,. � • - ' ' __ _ Cantacl the Davie County Environmental HeaHh Sectio�i for final inspectiou of Ih[s system berireen 8,30—9: Oa.m.on the dav ul'inct�ltation. Te1e kone It 336 751-87h0. • � ���� (�+N� K� G��wM� �- a�' �� ��bR �°°��t,� � � k . ��'�V�v'"��w�' PT �� � �� �,PQarr � ' �� • �('r M� I , �f�N ��,�V Gw..,rl , �—�- y�,�.a t s ' L l �.� - - ----_ � .__.._ `C a ow-Cvn�vs i;r�•ironmantal Itealth Specialisl_ _ _._._ .. '���.i__ Uate: .I•�`" ?'�� DCf ID i 1106(Revised) , � , r� � ' . � � Davie County Environmental Health • , , P.O.Box 848/210 Hospital Street Mocksville,NC 27028 (336)753-6780/Fax(336)753-1680 IMPROVEMENT PERMIT Account #: 990001724 Tax PIN/EH#: 5823-35-7658 Billed To: Tom Kitchene Subdivision Info: Address: P.O. Box 1549 Location/Address: Mortgage Hill Way-27028 City: Clemmons Property Size: 4.9 Acres Reference Name: Proposed Facility: Residence **NOTE**This Improvement Permit DOES NOT authorize the construction of a wastewater system. An Authorizazion 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. ._.�._._ .�_. _._ �--_.�___.._____�._. __ . . _ _..__.._._.__.._______.._.._._....__ Permit Type: ew ❑Repair ❑Expansion Permit Valid for: C�7"5 Years ❑No Expiration Residential Specifications: #Bedrooms 3 #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: C�'County/City ❑Well ❑Community Well �1s stateci in 15A n?C;f�C �.8�:.'!�;E=';�� Site Modifications/Permit Conditions: �rcA"-��� "`"'1�'`"•` "''k "'�'�`' �"� ' S stem T e LTAR Initial c , / Re air Site Plan \ ►, �� QU � �\ ��� . � R'� �� � � �� � d.� � L . �c'S a � J ` �l Environmental Health Specialist Date � � " 7—'� g �.. i.p.ll-06 �� �- � �- � � C� - '� �� ��-��-�c� ��,a -�--.� �,` ��� ��� .� � ,.o �,,�,�d �I' 7/ ------�r ��'�--�----."'^ � �, � �l � � � � � � P T ►� M �� � � � � � � � -�-��� .� � � � �. - _ , �'� ��c� � � �� �� �� � .��ss o - �b� ..e.awV q� JyJO� a-r,�ay��� wo / � � , ` �� � f . . • t '� � � • I . . t • . APPLICATION F R SITE EVALUATION/IMPROVEMENT PERMIT & ATC � a �n � Davie County Environmental Health ;'; (� v � P.O. Box 848/210 Hospital Street !���r�''`�f S Mocksville,NC 27028 ! r ;.e'',1���. �OV 1 3 �009 (336)753-6780/Fax(336)753-1680 pp1iGation For: �e Evalu ion/I provement Permit I�Authorization To Construct(ATC) ❑ Both ype QfA��li „ � }p� ,�, �W1 System ❑Repair to Existing System ❑Expansion/Modification of Existing System or Facility E�VIn��;,�`�n.,•,��Y *** 7�***THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. APPLICANT INFORMATION � Name to be Billed � o rn �� �C c�iv��— Contact Person j orv l� Bil(Yng Address •b, 13 oel l S�IQi Home Phone (¢�i,� — 0 5� S City/State/ZIP_C LQ rn nn�,,l S ��. �'1� �'�-- Business Phone �!o l� - 3�{S Name on PermidATC if Different than Above Mailing Address City/State/Zip PROPERTY INFORMATION *Date House/Facilit Corners Fla ed " "� NOTE: A survey plat or site plan must accompany this application. Included: ❑ Site Plan ❑Plat(to scale) (Permit is valid for 60 months with site plan,no expiration with complete plat.) Owner's Name `T'��prn�, s K�'f'c�4we Phone Number�3� (942 - 0555 Owner's Address (fll9l� (,��� t-b,,r�-- City/State/Zip Cjp�,��, � a�mr� Property Address r6 e�r City /YI D e/cfu�/(_¢, Lot siZe �.�' Tax PIN# � 3 00o e� o�f� 5��3-35-7(�s� Subdivision Name(if a plicable) Sect' ot# � Dir ctio To Site: U u! 0 Q!S e. 'l �o � aw c- If the ans er o any of the followin questions is"Yes", upporting documentation must be attached: Are there any existing wastewater systems on the site? Yes �No Does the site contain jurisdictional wetlands? Yes �No Are there any easements or right-of-ways on the site? Yes �No Is the site subject to approval by another public agency? Yes /No Will wastewater other than domestic sewage be generated? Yes 1No IF RESIDENCE FILL OUT THE BOX BELOW #People 2 #Bedrooms � #Bathrooms 2 Garden Tub/Whirlpool ❑Yes ❑No Basement: ❑Yes No Basement Plumbing: ❑Yes No IF NON-RESIDENCE FILL OUT'THE BOX BELOW Type of Facility/Business 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 sysfem is intended to serve? 0 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 permit(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 Department to conduct necessary inspections to detennine compliance with applicable laws and rules. I understand that I am responsible for the proper identification and labeling of property lines and corners and locat' b aggi staking the house/facility location,proposed well location and the location of any other amenities. �'� Site Revisit Charge Property owner's or owner's legal representative signature Date(s): ���Q� Client I�totification Date: Date EHS: • Sign gi��en !;Yes ❑No Account# _ /�Z� Revised 11/06 Invoice# �� ���7d, r� �--�.7J v n� — ` � �� l ��� � � �' ����� �1' � �� J� . - � � . �(^\ � ��r ( � V ` .,.1 � �. �J .� . ,� �..� j -�� ?( ,� ' , _�...,.- � ,�-� �� . i � �" � �� __ a j 1 t ��' � ' �� � �� � � � �� � ��... . �� ��� ' - � 4►�� �,�r� •�;��� ,vd , � � . -� s -��� � � . . ���,�a r`�' , RY � � , -�GoMAPS•-bavie County NC Public Access Page 1 of 1 . . Davie County, NC - GIS/Mapping System . ,d�0�U� + � ��] Qa�IF .- . � � __ _,,.. � �#: Click Here To Start Over �11�ec,: Se�.;�h:(Cci.�nt;� Id� or Ot��n�r N� �'� v'� • , • A�ti��a� L�;:�t r. D Use��tap irps �"`=�t���¢., �—�; � � � PARCELS (Map Tips Available) �- ri� _ _ _ Addre. ._ __-_ _ -- _____ _ _ ��_:-y. . _ � � I__ ..__.__� _._ ___ _ _.. � � _� f �, 1 , j i r i � � �- . ; ' � I� . I --- ���,���� � , � + 5 � � � �J ? �-------_ 1 ~, ,� 13 r � �-'{':� '{'��?1~ ���,—L . +t�� � '-� '`� f r �;�o c�cc�iii�� �::,;3�� '� �,.-; � M1�--_� � ..;_�� � i � �--�`- ,,, � r r � . - `---� -�`'� � ,��� - � � ����.� �--- f' � �-� � ���`�x� f � , _ � . r 1y__ - � �� � .t. ! !� `'� /` 1��..1. 7(,.I � � � {� I �- f: ~}'-. 1 1 +� r��� I J.;;`�,�'',.�ti �L r ��ri � � ( �� � 1 ��- f! ~ '� / r " � ! Q�= F�a �: ' �� f ~��+ � a�E:r•�s c:r e �r•a r , } ; 1 � r +�, `� - L �_ 1� f l�, l I 'J1I �� � / � ;� �`� � � � i � 1% `; r E,� 1�' ( ,r o r �' � � - ,; . f-- -�� ;- ;'.� � �' f I � � I , i;'' f'FI' i i f r I� q��7�ft---.,. f'`�_ �-� I �, http://maps.co.davie.nc.us/GoMaps/map/Index.cfm?mainmapservice=gomaps&CFID=41... 11/17/2009 ., � , , . . � � • � • - DAVIE COUNTY HEALTH DEPARTMENT . � � � Environmental Health Section , � � � Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990001724 Tax PIN/EH#: 5823-35-7658 Billed To: Tom Kitchene Subdivision Info: Reference Name: Location/Address: Mortgage Hill Way-27028 Proposed Facility: Residence Property Size: 4.9 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 osition 1� Slope % 2 HORIZON I DEPTH p — Texture grou Consistence Structure �j (� Mineralo 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 CLASSIFICATION LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: O ) EVALUATION BY: ��� / LONG-TERM ACCEPTANCE RATE: OTHER(S)PRESENT: REMARKS: LEGEND T,andscane Position R-Ridge S -Shoulder L-Linear slope FS -Foot slope N-Nose slope CC-Concave slope CV-Convex slope T-Teirace FP-Flood plain H-Head slope T�x�u'� 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 CnN�I T�,NC' . �1415� 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 Structure 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 � 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 suitabie),U(unsuitable) TTAR -T.nno-tP.rm arrPntanrP 1'A}P� OA�IlIAVIff7 Tl�TTTl�G/hC m___:__�� I ' , , �(�-�—`.`' �d / �.�-- � . • ` � � � � U � � ~ '.w � ' ' APPUC.ATION FOR SiTE EVALUIiTlON/IMPROVEM1�ENT PE-fit�31T�C � '_, ___. • � Davie County Heaith Department - ' ' Environmental Hea/tl�Se�ction AP R 2 7 2001 P.O. Box 848/210 Hospital Street Mocksville, NC 27028' (336)751-8760 Q'?l'�'�O��S"=��H� Dn`��E COUNIY ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED Z3NLESS ALI, THE REQUIRED INFOR2�ITION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. rr 1. Name to be Billed 1 �(Y` ���\�LL(� Contact Person Mailinq Addresa �� • y'!3� �J 7� Home Phone /�p(p '" 2 f 7� City/State/ZIP l",{Q�����1� (1✓�, ��('�l t� 8uaine s Phone /(�}� - � T J J~ 2. Name on Permit/ATC if Different than Above � �f' � (�/J f �'` " ��� Mailing Arldresa City/3tate/Zip 3. .Application For: 0' Site Evaluation ❑ Improvement Pezmit/ATC ❑ Hoth a. syet� to ser�,ice: ❑ House �Mobile Home ❑ Business ❑ Industry ❑ Other s. if xesidence: t People � � Bedrooms 3 # Bathrooms �� � �DishMasher II Garbage Diapossl }�Washing Machine U Basement/Plumbing ❑ IIusement/No Plwnbing J' \ 6. Z£ Buainess/Industry/Other: Speci£y type # Peopla # Sinks � Commodes # Shoxera # Urinals # Water Coolera IF FOODSERVICE: # Seats Estimated Water Usage (gallona per a�y) 7. 7�pe of water supply: � County/City O Well ❑ COmmunity e. Do you anticipate additions or ezpansions of the facility this system is intended to serve? ❑Yes �No If ycs,what typc? ***IAIPORTANT***CLIENTS MUST COMPLETETHE REQUIRED PROPERTY INFORMATION REQUCSTED BELOW. Either a PLAT or S1TE PLAN MUST BESUBMITT'ED by the client with THIS APPLICATION. Property Dimcnsions: G°��` �P `��"1'i't_ WRITE DIRECTIONS(from Mocksvillc)to PROPGK'I'1': —� Tax Once PIN: # _��� 3������ � c� �(�( `�O �d � � Property Address: Road Name ,9a.��. ��� CT� � City/Zip /,Ztit-C� G� U�7�J�� � If ia a Subdivision provide information,as follows: Name: - •�- Section: Block: Lot: � ` Date Property Flagged: �Z�—� 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 a�plicatioa is falsiiied or changecL I,aJso,understand lhat I am responsible for all charges incrrrred fronr this application. I,hereby,give consent to the Authorized Representative of the Davie County Healtt�Department to cntcr upon above dcscribed progc:ty LaeatcL in llavic County and owned by __ to conduct all esting procedures as necessary to determine the site su' ility. DATE .�7— o� _ SIGNATURE �. THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN(Include all of the following: Eaisting and proposed property lines and dimensions, structures, setbacks, and septic locations). Site Revisit Charge Date(s): Please complete the highlighted area(s)and return. Client Notification Date: EHS: � ;� ' �n � 1„ J� Account No. 6 ��C- Revised DCHD(07/99) Invoice No. ���' � ��-�� . ��-�s �- `�S `� � � " � � . , ' � - DAVIE COUNTY HEALTH DEPAR'TMENT , ";` : � ' � Environmental Health Section ,-� �c . � . Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMAT'ION--_:"._,._L� ,_.___ _ _ ;:�t��z:,.� y,= Account #: 990001724 . Tax PIN/EH#: 5823-35-78Q7:01 �... Billed To: Tom Kitchene -- " Subdivision Info: Reference Name: Location/Address: Four Comers Ro�270�8'�� Proposed Facility: Residence Property Size: 3.�acres Date Evaluated: � b� Water Supply: On-Site Well Community Public �� Evaluation By: Auger Boring L� Pit Cut FACTORS 1 2 3 4 5 6 - 7 Landsca e osition L Slo e% HORIZON I DEPTH Texture rou Consistence Structure Mineralo HORIZON II DEPTH � '' O' 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 CLASSIFICATION ° LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: EVALUATION BY: LONG-TERM ACCEPTANCE RATE: � OTHER(S)PRESENT: REMARKS: v`�^���Z�' ��C N ���� LEGEND Landscape Position R-Ridge S-Shoulder L-Linear slope FS-Foot slope N-Nose slope CC-Concave slope CV-Convex slope T-Tenace 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 Mineralo�v 1:1,2:1,Mixed Notes 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■■�����■■■����■�■�■■��■■�■■■■■���i�■■�■■■■■■■�■��■■■■�■���■■■■■■�■ ■��■■■���■■■■■■■■�������■�■�■�■�■■�■����■■�■��■��■■�■■■����■■■■■�■ � , � . � � - - ����v�,o � � !�, - .'APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERNIIT ������ ' '� Davie County Health Department � � ' ��(,� ' � Environmental Health Section � cy� , �/�,,�� -p� �'�l � � � /" 7T� /at'e� l� /`� . �a � � � ��� G � n � t,J, �f P. O. Box 665 �� """J � iZ .`' � Q� _. .�^ 1.�. �j,i ;�� Mocksville. NC 27028 . ..... .. . . ._.....���Ox��3 �' � . 1 �w���J �I � � � A� / P � G � � �,C o e S . � • � � d- <��C—Lr V'" �� �C � 1. ApplicaUon/Permit Requested By �� �' 0 +'�� Mailing Address t (...: Home Phone Q � Ja ' ` � �/1� � � Business Pho �D.��' 3J ✓� � 2. Name on Permit if Different than Above �"�'��`-� 3. Application for: [�General Evaluation eptic Tank Installation Permit l��l'�S��J 4. System to Serve: �Flouse ❑ Mobile Home O Place of Pubiic Assembly ❑ Business ❑ Industry ❑ Other ❑ Unknown 5. If house, mobile home: Subdivision Section Lot # ❑ BasemenUPlumbing No. of People /� O BasemenUNo Piumbing No. of Bedrooms � ❑ 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: ����ublic ❑ Private ❑ Community 8. Property Dimensions�� � e� Sewage Disposal Contractor 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes ❑ No � If yes, what 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: . ,� �� � ���-- ��� �o �-��,�-� — o�� l , � _ - �_ � � _ � . . c- ,� � � �� �� � This is to certify at th information provided is correct to the best of my ledge, d I u erstand I am responsible for all charges incurred i th'pyap ication. 9 -' -1 � �= ATE SIGNATURE CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY MUST CHECK ONE: ❑ 1. I OWN the property. p�2. 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 D vie o nt Health De art ent to enter upon a ove de cribed property located in Davie County and owned by 0 .S to conduct all testing procedures as necessary to determine sai e's suita 'lity f a ground absorption sewage treatment and disposal system. ��1.�=�� DATE SIGNATURE pCHD(1/93) � v� � � � ' DAVIE COUNTY HEALTH DEPARTMENT • �. ' . Environmental Health Section � Soil/Site Evaluation NAME DATE EVALUATED �/1��,� ADDRESS PROPERTY SIZE S� /��� PROPOSED FACIILTY LOCATION OF SITE "��`/G'�'liS� Water Supply: On-Site Well Community Public �/ Evaluation By: AugerBoring (/ Pit �/' Cut FACTORS 1 2 3 4 Landsca e osition L .L ,C_ �- S 1 o e 7. ' .�.. '7 � HORIZON I DEPTH �� �� �� �� Texture rou � G' Consistence Structure Mineralo HORIZON II DEPTH , �" ~ ��/'' " Texture rou /' C. Consistence ' : ,l.• ,= Structure /'� i� : !/.� � ,/ Mineralo , ,� .� HORIZON III DEPTH Texture rou Consistence Structure Mineralo HORIZON IV DEPTH Texture rou Consistence Structure Mineralo SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION I�S LONG-TERM ACCEPTANCE RATE , �'- SITE CLASSIFICATION: /J ��f�4�� �1! ��- EVALUATED BY: /��1`� LDNG-TERM ACC�E,PTANCE R?TE: �� OTHER(S) PRESENT: REMARKS: ('�'v'li'��Z�(� p ; �f" �S'�CiiZ — EGEND Landscape Position R-Ridge 5-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 c:lay loam� SIL-Silty loam CL-Clay loam SCL-Sandy clay loam SC-Sandy clay SIC-Silty clay C-Clay CONSISTENCE Moist VFR--Vc.�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 Structurc .iC-Syngle grain M-Massive CR-Crumb GR-Granular ABK-Angular blocky SBK-Subangular blocky PL-Platy PR-Prismatic � Mi neralo�y 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 wate� 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 ■�/��������■ ■■������������■������\�����■ ■���■ ■����■����■��������■������■ ■����■■■ ���■���������������■����������������\■��������������������■��������■■������������■�■ ■�■����■�■�����������■■������������■�����■�■��■�����������������■�■����������■�����■■ ■������■��■������■�����■�■�■����■������������������■■����������■��������■������■■�\�■ ■�H��■��■������� ������������■���������������������������■■�����■�■��������■����■��■ .................C...... ............................................................ ........................C. .......................................................... ......... ... ........ ..C............................... .......................... .........C...1........�................. ........... ..._.......................... .........................................�i..........._.............................. ............... ........................ ............................................ ..�............0..................................................................... .. ................................... .............................................. ........................ ............ 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BOX 665 MOCKSVI��E.N.C. 27028 PHONE:(704)634•5985 July �0, 1994 Kim & Shelia Young c/o Howard Realty P. 0. Box 553 Mocksville, NC 270�8 Re: Site Evaluation Four Corners Road/6. 831 Acres Dear Mr. & Mrs. Yot�ng: As requested, a representative from this office visited the aforemEntioned site on J��ly 19, 1994. Based upon the information pr-ovided on the application for a site evaluation and after the evaluation was completed, the site was found ta be provisionally suitable for, the installation of a modified, oversixed on—site sewage disposal system. If yau have any questions, please feel free to contact this office. Sincerely, ��•�f��✓6��/'�/�'� � % Robert B. Hal l, Jr. , R.S. Envir•onmental Health Section RH/wd " � Enclosure • . . , ' - . • � ,,. ,. _ .:.:� ,. . . ._ . .. ...:.. .... .. ..�::...�D��I�r�QUNTY��i�LTiI I}E���T14I�R1T `. ENVIROIVMEIVTAL HEAITH SECTION P. O. Box 848/210 Hospital Street Courier #09-40-06 Mocksvilie, NC 27028 Phone #: (336)757-8760 May 10, 2001 Tom Kitchene P.O. Box 1549 Clemmons,N.C. 27012 Re: Site Evaluation/Four Corners sites 1 and 2 Dear Client(s): As requested, a representative from this of�ce visited the aforementioned site on May 8, 2001. Based upon the information provided on the Application for Site Evaluation and after an evaluation was completed on the site, the site was found to be provisionally suitable for the installa.tion of a modified, oversized on-site sewage system. Before an Improvement Permit/Authorization to Construct can be issued the appropriate application must be filled out and the house/mobile home location staked off. If you have any questions, please feel free to contact this office. Sincerely, ,��;�,t��,/��. Robert B. Hall, Jr., R.S. Environmental Health Specialist RH/di Enclosure(s)