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Main Church Road Lot 4 . ✓. APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERAI V Davie County Health Department Environmental Health section APR 2 6 2008 P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 W�NECpU HEApH ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. Refer to theQ INFORMATION BULLETIN for instructions. 1. Name to be Billed C I-IA M'o VJ , f) u- Contact Person . U�Cn Mailing Address Za) GI.1�1•ta L.14 CA 1.l� GLyr e 33�' / ej?- 9(o L1 7 /1� City/State/ZZP � QC1L S V/ l.Ll N CZLpZ� Business Phono 2-36` 99 - 1733 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 Service: YHouse ❑ Mobile Home ❑ Business ❑ Industry ❑ Other 5. Type system requested: Conventional ❑ conventional modified ❑ innovative 6. If Residence: # People � # Bedrooms it Bathrooms Z '1 1215ishwasher ❑Garbage Disposal gashing Machine Mrasement/Plumbing ❑basement/No Plumbing 7. If Business/Industry /Other: verify type # People t# Sinks # Commodes #I Showers t# Urinals 0 Water Coolers IF FOODSERVICE: It Seats Estimated Water Usage (gallons per day) S. Type of water supply: ❑ County/City 13/Well ❑ Community 9. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑Yes ❑No _ If yes,what type? I***IMPORTANT***CLIENTS AIUST COAIPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Eithcr a PLAT or SITE PLAN AfUST BESUBAIITTED by the client with THIS APPLICATION. Property Dimensions: SL t` 60(A'r WRITE DIRECTIONS(from Mocksville)to PROPERTY: Tax Office PIN: IE 5•-7 y 9 O 9 2 )—1(-j QS 1158 %O ;iV)41)'IC N 9 d i l Property Address: Road Name I'1i(AtN Cflyrt,GH ►2.o SI r%F 1S LQ C-AT1v citymp�o t:LN I L-u 1NJ ( ) 1'A-1 u,. -4- u N La= ---r 27 OZ$ If in a Subdivision provide information,as follows: Name: �C�--r-f Z;)2 S F- )(F L.YJ (E S 14 Tc� Section: Block: Lot: 3 Date home corners flagged: — 3 ) — CO 5 This is to certify that the information provided is correct to the best of my knowledge. I understand that any permit(s) issued 1lereafter 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. 1,also,understand that I ala responsible fur all charges incurred froru: this application. I,hereby,give consent to the Authorized Representative of the Davie County Ilealth Department �J to cuter upon above described property located in Davie County and owned by 121 C14At? to conduct all testing procedures as necessary to dclermine.the site stability. 5 ` DATE ��/ _� SIGNATURE' TIlIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN(Include all of the following: Existing and proposed property lines and dimensions, structures, setbacks, and septic locations). Site Revisit Charge Datc(s): Client Notification Date: t EIIS: Sign given Account No. Revised DCHD(05103 Invoice No. �° 9 G✓ f DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Agpount #: 990003603 Tax PIN/EH#: 5749-09-2174.03 RB Billed To: Richard Bell Subdivision Info: Potters Field Estates Lot#03 Reference Name: Location/Address: Main Church Roa 7 Proposed Facility: Residence Property Size: see plat 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 L, Slope% HORIZON I DEPTH e--'e,- Texture group Consistence Structure Mineralo - HORIZON II DEPTH Texture group Consistence - 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: Com_ , EVALUATION BY: LONG-TERM ACCEPTANCE RATE: OTHER(S)PRESENT: t CC G Ott 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 Textu 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 ois VFR-Very friable FR-Friable FI-Firm VFI-Very firm EFI-Extremely farm 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 DCI ID 05/99(Revised) ■.■.■./..■■.ee■.■■■....■.eeeee.■me■■.■■■■■■■e■.......e.N.■e■r■■■e■ ■..■■.//■.■e..■■■■■■■...Rae.cera►�►eeeeseee■■■■■e.....■■.■ree■■ ■.■ ■■.■e■eere..eee■.■Oe.....■.ne.e■ ■eeeee.e■■O■■■eeR...■.■e/■ ■ MEN ■..■...■...■■ee■■■■■■■...e..ee■■e/NNe■eeee.■.■■..ee■..■e■u■.6■ ■■■ ■.....■../■■■rreee■■■e■■..e...e■■maeeeee.ee■.■■■e■■.■■.....■■.■ ■ ■ ■........./.■e■■e■■e■e■....eee■■re■.ene..e...........■rr.■..�_ ' ■6 ■■.......■■■■e■■s......■..■■■■.....ee.■■.e■■...o...■■......■ _ ■.......■■e■■ee■■e.ee■e■■.■■.■■e.rrre■eeeeee........■.■■■..■C ■■ ................................ ................... .. .■. ■■ ■..■o.e...ee■r.ee■■■■..■s.■t.■...■■..■.■.■..t.■■■.rr■...rr.■ ■� ■■ ■eee■■■eR..R.■Ne/eeeee■ee■■.■■■..n..■.■t..■■..■■■■■ee.......■ ■ ■■■■■■■■.■......■■■■■r■■■ee■■e■u■■.....■...■.eeeee.e■eeee.■ ■■ C■ ■■■■■eee.■■.■..■e.e■■■■..■■eee■►■......■.■.■.r....ee...e.e■■ ■ ■■■ ■■ee■e....■..■......■.■..■....■■■■■eM.e■.........e.■■r..■■■�:: :■■ ■.■■■■■■e..■e.O■■...r■■r■■r.■■/eH1;.......e.....■■.■e....ee■ . ■■■ ■■■/■■■.■■■■■■■■......■■■.■■■.■/dire..........■■...■....■■■■ in r.■ ::MNON :::::::::::::::::::::::�:�mommusommummommomm::::::.■66: 6: .....■.........................,��■................■.....e. .0 ■■.■■■..eeeeeen■■■...M.....■■.►�Ie�7■.e.■■.ee.e■.■■.■■....■ ■ IN : ■■.ee■e.eNee■eee■■ee■■■M■■■..■r�rli/■■/.■■...eees....■.....■6eMNON ■..■■■■...■■■..■■■■■■ecce.M■■v■I. ii..rete■■r■■■e■■.■.r.■■■..■ ■ ■ ■ee■..■■■..e.■rrnnee■ecce....■■i,-�■■■■r.■■ee.■r■r■.rrr..mom ■ ■ ■.era■. ■...■■■■.■■■■■rr■e....■,r�a�r■...■.er.e.er■■..eee..■..■ :■..■ ■.■■eee:■■■..■■.■nnenee■■nee■■/�L�M■■e.ee■■■■■rnee.■eee.e......s.... ■nee...e.e...er■■rrereeee■eee.►i....■..■■.....■e■s■e.e■..■■■. ee ■. ■■■ne..■■..■....■n■■e■■reee■r►rig.■..ee...e■■■r..e.e■r■■e■....�Cr ■■ //./■.�►■■■■..►�.■■■.■�►ere.,�1.�......�►.■■.n.�l.e.■■.►�►■■ ■ ■EM■O■ ■.M■O■ Naar.■ ■■■/!ZI] " ■■Nee■ M■MM■N Nauman : ■■.■nm■Nee■■■.■■.■■RR■■■■■■■■.info■e..e.....■■..■■.....rr.r: 6 ■■ arae.■eee......■■...■■.■.�u■■rer..r......r.■.r.r■r.■r■ ■ ■■ ■■mer■■e■■rrr.r■■.....■e.■►Irrerre...■.■■■■■■■.■■■.■■..►� 6 6 ■..�■ecce.■.rerrr■■.■r■■■...■r��■■M■Me■■..........■.......■ ■ ■8 ■■s ■eee■rreee.........■■■■.■�.r.�reee.■...■....■.■■■■■.■ ■ ■ ■ ■■■r�°ererrrs■ewer■..■.■■.■■■.■e ►■■eee.n....■...■....■■■6■■:�...■ MOOR. ■■■■■■■■■ane■■OM■......11■Orr■.n■Nee■■■■■...■eee....■ ■.=r■ ■..■M6�.■■■e■■■mee■■..e■■■e..■1lrrnrrnrrn■■re■Nee■ee..M.■e.� �u■■N■ ■NOON ■■e■■umrn■■M■■eee■■■■■.11■Rmmeer■.Ne■Neeue.e.■■e■e.■ ■ ■ ■e.■■.ee ■■r■■..■r.■ee.......■�.■.nr■r.e.rnreree.e.......M.. 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Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 ONMENTAL HEALTHAMECOUNN F***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED , INFORMATION- IS PROVIDED. Refer to theINFORMATIONBULLETIN for instructions. 1. llama to be Billed � 1liNI'a11'V VJ r IJLL�- Contact Person �J�Cn L STV N L Mailing Address Za) r-.14rtJ iJ rr L LA iJ C �iLL e 3�' Zj 2' CI(O !7 City/State/ZIP N (- 2.-70ZBusiness Phone 998 - Ll '7.3'3 2. llama on Parmit/ATC if Different than Above_ Mailing Address City/State/Zip 3. Application For:. .�a Site Evaluation 13 improvement Permit/ATC ❑ Both t71' 4. System to services H�/ ouse ❑ Mobile Home ❑ Business ❑ Industry ❑ Other S. Typo system requested: 19 Conventional ❑ conventional modified ❑ innovative 6. If• Residence: People , 0 Bedrooms _ # Bathrooms _ Z Z LJDishwasher ❑Garbage Disposal Washing Machine I2iasement/Plumbing ❑Basement/No Plumbing 7. If Business/Industry /other: verify type # People # Sinks # Commodes # Showers # Urinals # Water Coolers IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day) S. Type of water supply: ❑ County/City I/Well ❑ Community 9. Do you anticipate additions or expansions of the facility this system is intended to serve?❑Yes ❑No If ycs,What type? I***IMPORTANY"*CLIENTSdIUSTCOMPLETETIiE REQUIRED PROPERTY INFORMATION REQUESTED BELONY. Eitliera PLAT or SITE PLAN J11USTBESUBMITTED by the client ivitli TIIIS APPLICATION. Property Dimensions: SL t= AA T WRITE DIRECTIONS(from Mocksville)to PROPERTY; Tax Office PIN: 11 5-1 y9 09 2 )-LI V S 1 5 %0' )/;I4 1^1 C H Property Address: Road Name IMatN C9VA'GH f.)o S/ Z 1S LU "�1Ti citymp 610 L ILf J I t_o-i I.\S (_ ) i tom- U N L= --'T • 2�o�z8 If in a Subdivision provide information,as follows: Name: �c��T�(L S F- )L L YJ t S 14-F& Section: BIock: Lot: Date ]ionic corners flagged: ' - E ) - O S This Is to certify that the information provided is correct to the best of my knotiviedge. I understand (fiat any perniit(s) issued Hereafter are subject to suspension or revocation,if file site plans or intended use change,or if the information submitted In this application is falsified or clianged. I,also,understand that I mn responsible for all charges incurred fnoln this application. I,hereby,give consent to the Authorized Representative of the Davie County I-Icalth Department to enter upon above described property located in Davie County and owned by 1 6A 21 S ✓1't,CN LR-67 1 \-L- to conduct all testing procedures as necessary to determine.(lie sit iitability. DATE Ll �D 5 SIGNATURE, 90"&Jr TIIIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN(Include all of the following: Existing and proposed property lines and dimensions,structures, setbacks, and septic locations). Site Revisit Charge Datc(s): Client Notification Date: EHS: 4 Sign given _ Account No. �'"� 3 Revised DCI--ID(05/03 Invoice No. / / - - DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account:#: 990003603 Tax PIN/EH#: 5749-09-2174.04 RB Billed To. Richard Bell Subdivision Info: Potters Field Estates Lot#04 Reference Name: Location/Address: Main Church Road-27028 Proposed Facility: Residence Property Size: see plat 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 Slope% HORIZON I DEPTH e. Texture grouRL Consistence I Structure Mineralogy HORIZON II DEPTH Texture group Consistence 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 f SITE CLASSIFICATION: EVALUATION BY: G� LONG-TERM ACCEPTANCE RATE: OTHER(S)PRESENT: REMARKS: ew✓�_--- LEGE 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 ois 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 truct rc '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 !ll'FI1)p5/u9(Revised) ■(rC■./■■///.////./■/..■■■.■■■■/.■t�r.ee.■..■■.■■.■■■■■.e■■.r■ ■■ ■t■ ■Ir■■■.■e■■■.■■r...■■r■...■■er..■ ■■ee/..■■re.■e..■■.■e..t.■�ei../ ■rr....■.■■..■■■..■.■■.■■■■..■■....■■.■■■..■...■■.......■■.■■ ■ ll .Ilr...rr■..t.r.■r■rt....■c�..r■..............................� CCC. ■r........................................................... ■ll..ee/.■.■■..ee■...■■..■I,e.■.....■...■■■...■....■.■■r.e.■rr on .tlt.■.■....■■■■.■■....r...urtttr■t�..rrrrr■..■....■■■■_■■.... r�■ ■ 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