188 Ashley Brook Ln Lot 8 ` DAVIE COUNTY ENVIRONMENTAL HEALTH
' P.O.Box 848/210 Hospital Street P `
Mocksville,NC 27028
(336)753-6780/Fax#(336)753-1680 V!`
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
Account #: 990004483 Tax PIN,EH#: 5729-66-5406
Billed To: Jane Whitlock Subdivision Info: Richardson Estates Lot#
Reference Name: Revised: 6/29/11 Location/Address: Ashley Brook Lane-27028
Proposed Facility: Residence Property Size: 125 195x125x
Site Type: Ci ew ❑Repair ❑Expansion
ATC Number: 4792
**NOTE**This Authorization to Construct(ATC)MUST BE ISSUED by the Davie County Environmental
Health Section prior to issuance of any building permit(s),(in compliance with Article 11 of G.S.Chapter 130A
Wastewater Systems, Section.1900 Sewage Treatment and Disposal Systems). THIS AUTHORIZATION TO
CONSTRUCT IS VALID FOR A PERIOD OF FIVE YEARS. This ATC is subject to revocation if site plans,plat
on the intended use change.
Residential Specifications: #Bedrooms #Bathrooms #People_,,�L Basement❑ Basement plumbing❑
Non-Residential Specifications: Facility Type #People #Seats
Square Footage(or Dimensions of Facility)
��'
Lot Size Type of Water Supply: ❑County/City , �V{� ell ❑Community Well
System Specifications: Design Wastewater Flow(GPD)�Tank Size '/ GAL.Pump Tank JXAL.
Trench Width 36.` Max.Trench Depth 3Z Rock Depth Linear Ft.3 V7
Site Modifications/Conditions/Other:
Contact the Davie County Environmental Health Section for final inspection of this,system between
8:30-9:30a.m:on the day of installation. Telephone# 336)751-8760.
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DCHD.11/06(Revised) ,
1
DAVIE COUNTY ENVIRONMENTAL HEALTH
P.O.Box 848/210 Hospital Street
Mocksville,NC 27028
(336)751-8760 Fax#(336)751`-8786
OPERATION PERMIT
Account #: 990004483 Tax PIN/EH #: 5729-66-5406
Billed.To: Jane Whitlock Subdivision Info: Richardson Estates Lot#8
Reference Name: Location/Address: Ashley Brook Lane-27028
Proposed Facility: Residence Property Size: 125x195x125x
ATC Number: 4792
**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.
CJ
System Type: � S.T.Manufacturer 5 Tank Date Tank ize�
Pump Tank Size
System Installed Ey: 0 G E.H. Specialist: Date:
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DCHD 11/06 (Revised)
APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC
Davie County Environmental Health
�✓E,V E P.O.Box 848/210 Hospital Street
JUN 2 2011U Mocksville,NC 27028
p (336)753-6780/Fax(336)753-1680
Application Y. mprovement Permit ❑ Authoro on To Construct(ATC) ❑ Both
Type of Application: ❑New System ❑Repair to Existing System L5Expansion/Modification of Existing System or Facility
***IMPORTANT*** THIS APPLICATION CANNOTBEPROCESSED UNLESS ALL OF THE REQUIRED
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
APPLICANT INFORMATION
Name �}�/1 e W h d l oe_k Contact Person
Address nV0A 741 /Z� AitIP� Home Phone —
City/State/ZIP A0SI V"Ille-' 77.10 9 Business Phone
Name on Permit/ATC if Different than Above
Mailing Address City/State/Zip
PROPERTY INFORMATION *Date House/Facility 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 < 01 14 19- Phone Number
Owner's Address City/State/Zip
Property Address City
Lot Size Tax PIN# - &6-W06
Subdivision Name(if applicable) I dA/Ala Section/Lot# b
Directions To Site: S
If the answer to any of the following questions is"Yes",supporting documentation must be attached:
Are there any existing wastewater systems on the site? _Yes 4lo
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 /No
IF RESIDENCE FILL OUT THE BOX BELOW
FBa
eople #Bedrooms #Bathrooms Garden Tub/Whirlpool ❑Yes ❑No
sement: ❑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: e onventional ❑Accepted ❑Innovative ❑Alternative ❑Other
Water Supply Type: ❑ County/City Water T' ew Well ❑Existing Well ❑ Community Well
Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ 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 pen-nit(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 determine compliance with applicable
0<_RN rules. I understand that I am responsible for the proper identification and labeling of property lines and corners and
11ocatingland Yng11 0skithe u e/facility location,proposed well location and the location of any other amenities.
Wo e owners or owner s lega rep sentative signature Site Revisit Charge
6)1
Date(s):
t r2 Client Notification Date:
Date EHS:
Sign given OYes ❑No Account# Y
Revised 11/06 Invoice#
DAVIE COUNTY ENVIRONMENTAL HEALTH
P.O.Box 848/210 Hospital Street
Mocksville,NC 27028 �(
(336)751-8760 Fax#(336)751--8786 ' U
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
Account #: 990004483 h Tax PIN/EH#: 5729-66-5406
Billed,To: Jane Whitlock Subdivision Info: Richardson Estates Lot#8 *ff
Reference Name: Location/Address: Ashley Brook Lane-27028
Proposed Facility: Residence Property Size: 125x195x125x
ATC Number: 4792 .
Site Type: ❑New ❑Repair ❑Expansion
**NOTE**This Authorization to Constrict(ATC)MUST BE ISSUED by the Davie County Environmental
Health Section prior to issuance of any building permit(s),(in compliance with Article 11 of G.S. Chapter 130A
Wastewater Systems, Section.1900 Sewage Treatment and Disposal Systems). THIS AUTHORIZATION TO
CONSTRUCT IS VALID FOR A PERIOD OF FIVE YEARS. This ATC is subject to revocation if site plans,plat
or the intended use change.
Residential Specifications: #Bedrooms 0, #Bathrooms #People Basement❑ Basement plumbing❑
Non=Residential Specifications: Facility Type #People #Seats
Square Footage(or Dimensions of Facility)
Lot Size �� "� -� Type of Water Supply: (C�unty/City ❑Well ❑Community Well
System Specifications: Design Wastewater Flow(GPDj2_q0 Tank Size/ GAL.Pump Tank AAL.
Trench Width Max.Trench Depth 34, Rock Depth Linear Ft.
As stated in 15A NCAC 18A.1969(5) p-P a.y�� J�-1 .y
Site Modifications/Conditions/Other: accepted S�'ntsms May '!. :, PIP u
Contact the Davie County Environmental Health Section for final inspection of this system between
8:30—9:30a.m.on the day of installation. Telephone#(336)751-8760. \ '
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,pc3lf ikeck 72 u
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Environmental Health Specialist Date:
v
DCHD 11/06(Revised)
1
pLIC JO SITE EVALUATION/IMPROVEMENT PERMIT & ATC
`"� Davie County Environmental Health
P.O.Box 848/210 Hospital Street
Mocksville,NC 27028
(336)751-8760/Fax(336)751-8786
A ion For: q Site Evaluation/Improvement Permit ❑'Authorization To Construct(ATC) 9 Both
Type of Application: )(New System ❑Repair to Existing System ❑Expansion/Modification of Existing System or Facility
***IMPORTANT***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 )h')4-1Dck- Contact Person cJ W Ytor k
Billing Address Home Phone Cel/
City/State/ZIP p Business Phone >3
Name on Permit/ATC if Different than Above
Mailing Address City/State/Zip
PROPERTY INFORMATION *Date House/Facility Corners Flagged a b 7
NOTE: A survey plat or site plan must accompany this application. Included: DKSite Plan ❑Plat(to scale)
(Permit is valid for 60 months with site plan,no expiration with complete plat.)
Owner's Name Ja ne W h!fl 0 CIC Phone Number 33(o-9 ifO'7115 t{
Owner's Address 202L i6hk,4 8r6l)Jin e_ City/State/Zip aMCk6V1 J(e� IU- ,7D,2-
Property Address City
Lot Size 1 a 5 X x <j Tax PIN#
Subdivision Name(if applicable) Q d nSection/Lot# B
Directions To Site: CIALIbAl Jew bn h-',h) A (L L-n pay-nej pyo J; 5ce-
Qlx}'�-OIC.)'1�c1 Y11A.n
If the answer to any of the following questions is"yes",supporting documentation must be attached.
Are there any existing wastewater systems on the site? ❑Yes KNo
Does the site contain jurisdictional wetlands? ❑Yes Wo
Are there any easements or right-of-ways on the site? ❑Yes BNo
Is the site subject to approval by another public agency? ❑Yes CgNo
Will wastewater othei than domestic sewage be generated? OYes.®.No
IF RESIDENCE FILL OUT THE BOX BELOW
#People _/ #Bedrooms 0— #Bathrooms Garden Tub/Whirlpool ❑Yes 1KNo
Basement: ❑Yes �ZNo Basement Plumbing: ❑Yes 54No
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 3'New Well ❑Existing Well ❑ Community Well
Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes ,KNo
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 determine compliance with applicable laws and rules.
I understand that I am responsible for the proper identification and labeling of property lines and corers and locating and flagging
or staking the hquse/facili–ty ocat' n,proposed well location and the location of any other amenities.
el-�A-
Site Revisit Charge
Prope owner's or owner's legal.representative signature
Date(s):
Client Notification Date:
Date EHS:
Sign given []Yes ❑No Account#
Revised 11/06 Invoice# �
i
GoMAPS - Davie County NC Public Access
SKATER SagN D
COUNTY_BOUNDARY
t ,STREETS..
RAILROAD CENTERLINE
PARCELS
01 CITY LIMITS
a SERWJDA RUN
4COOLEEMEE
LIAVIL'tXi{UTY
oN
tYCeR
o Mt?C"SVILLE
1
y Tuesday,November 13 2007
l
f
$ � f
0 o312ft l Hca`
***WARNING:THIS IS NOT A SURVEY!***
This map is prepared for the inventory of real property found within this jurisdiction,and is compiled from recorded
deeds,plats,and other public records and data.Users of this map are hereby notified that the aforementioned public
primary information sources should be consulted for verification of the information contained on this map.The
County and mapping company assume no legal responsibility for the information contained on this map.
f r
GoMAPS - Davie County NC Public Access
WATER BS&gND
COUNTY BOUNDARY
125 PARCEL DIMENSIONS
a ADDRESS
de DRIVES
STREETS
• w RAILROAD CENTERLINE
ED PARCELS
o CITY LIMITS
El8E MUDA MM
ElCOOLEEMEDAVIS COMY
EJMOCKSVILLEv
0
202 ,
S HL 0 I
t As Friday,November 23 2007
***WARNING:THIS IS NOT A SURVEY!*** `
This map is prepared for the inventory of real property found within this jurisdiction,and is compiled from recorded I�h
deeds,plats,and other public records and data.Users of this map are hereby notified that the aforementioned public
primary information sources should be consulted for verification of the information contained on this map.The
County and mapping company assume no legal responsibility for the information contained on this map.
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
APPLICANTI O TI TT ,I'ItIOtPEIiJnY INFORMATION
ccoun 3 Tax PIN/EH#: 57 -
Billed To: Jane Whitlock Subdivision Info: Richardson Estates Lot#8
Reference Name: Location/Address: Ashley Brook Lane-27028
Proposed Facility: Residence Property Size: . 125x195x125x1 Date Evaluated: — - �{
}
Water Supply: On-Site Well Community Public
Evaluation By: Auger Boring i�'�f Pit Cut
FACTORS 1 2 3 4 5 6 7
Landscape position L L_
Slope%
HORIZON I DEPTH C+ - 1-1,5-
Texture
-1,Texture grou 5C P _ G
Consistence �-
Structure
Mineralogy
HORIZON H DEPTH 3- V4_
Texture rouConsistenceStructureMineralo HORIZON III DEPTH
Texture group
Consistence p '
Structure
Mineralogyr
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE O. 7. 7 `-
SITE CLASSIFICATION: EVALUATION 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
Textures
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
C:QNSISTF,NCR
Moist
VFR-Very friable FR-Friable FI-Firm VFI-Very firm EFI-Extremely firm
WKI
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
Mineraloav
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,(1rovisionally suitable),U(unsuitable)
LTAR-Long-term acceptance late-gal/day/ft2 DCHD 05/05 (Revised)
■■eeeeeee■ee■■■■e■■eeea■■■■■■■■■■■■■■■■■■■■■■■e■■ee■■■■■■e■ee■e■■■
■■■/■■■■■/■■■■/■■■■s■e■■*�c■:ccs■r■■a■■■■■■■■■■■■■■■■/■■■■■■■■■/■■■
■■/■■■■■■■■■■■■■■■/■■■t■■■1�'".1■e■ /%it■■■■■/■■■/■■■■//■■■■■■■■■■■■■
■■■■■■■■■■■■/■■■■/■■■■Il■rice■/■■■■a��■■■■■■■■■■■e■■/■■■■■■■/■■■■■■■
■■■■■■■■■■■■■■■■■■■■■■If;�t�■�■■■■■■■�:iii■/■■■■■■■■■■■■■■■■■■■■■■■■■■■
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■■/■■■■■■■/■■/■/////■■11/■///■■/■■/�■It/■■■■■■■■■■■■ee/e■■■■■■■■■■/■
■/■/■■■■■■//■■ecce■■■■11■�ra�■■e■■■�:■11■■e■■e■■eeeee■■■e■■■■■■e■■■/■
■■/■■/■■/■■■■/■■■■■■/■/■■■■■i�ii�w�ie9�!�IM9■eE'dE�IJJI�■mfr/C�ii1/■G'�e■cell/■
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MENNENMENNEN MEEMEMmsmmomMEMNON MENNEN
■■■■/■////■/■///■■■■■■■■seee■■es/e■■/■■■e■■■e■ee■■■■■eee■■■■■■■■■■
■■■■ee/■/■ecce■■■■■■e■eee■■e■■■■■■■■e■■■e■■■■■■e■■e■■ee■e■eeee■■■■
■■■■■/■■/e■/e■■e■■ee■■■/■■e■ee■■eee■■e■/e■■■■//■///■/■//////■/■■■■
■/■/■e■■/■■/■/■/■■ecce/■//■////■■■■/■////■■///■■■■■■///■■■■■■■/■/■
■■■■■■■■■■■■/■■■■■■■■■■■■■■■■■■■Iii■■■■■■■/s/■■■■/■■■■/■■/■■■/■■■■■
Davie County Environmental Health
P.O.Box 848/210 Hospital Street
Mocksville,NC 27028
(336)751-8760/Fax(336)751-8786
IMPROVEMENT PERMIT
Account M 990004483 Tax PIN/EH#: 5729-66-5406
Billed To: Jane Whitlock Subdivision Info: Richardson Estates Lot#8
Address: 202 Ashley Brook Lane Location/Address: Ashley Brook Lane-27028
City: Mocksville Property Size: 125xl95xl25x
Reference Name:
Proposed Facility: Residence
**NOTE**This Improvement Permit DOES NOT authorize the construction of a wastewater system. An
Authorization 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: (e4ew ❑Repair ❑Expansion Permit Valid for: Years ❑No Expiration
Residential Specifications: #Bedrooms a- #Bathrooms #People Basement❑ Basement plumbing❑
Non-Residential Specifications: Facility Type #People #Seats
Square Footage(or Dimensions of Facility)
Design Flow(GPD): �Ly d Type of Water Supply: UCounty/Ci W ❑Community Well
As stated in 15A NCAC 18 .1�69e(0
Site Modifications/Permit Conditions: accepted system.
System Type LTAR
Initiala,Jr Q 0r 7
Repair '7 S
LA
. V
.fin:�•�2
J � �
5
Environmental Health Specialist Date
i.o.l 1-06
Excise Tax:$-0- Recording Information
Drafted by:Tamara A.Fleming,Attorney at Law,Ten Court Square,Mocksville,NC 27028
Mail to:Grantees @ 202 Ashley Brook Lane,Mocksville,NC 27028.
Property Address: 188 Ashley Brook Lane,Mocksville,NC 27028
TAX MAP: H-3-4,Blk A,Pcl 13
WARRANTY DEED
THIS DEED made this_day of August,2011,by and between JANE B.WHITLOCK
(a free trader)(Grantor Address:202 Ashley Brook Lane,Mocksville,NC 27028);hereinafter
referred to as the GRANTORS, to ASHLEY BROOK WHITLOCK (Grantee Address: 202
Ashley Brook Lane, Mocksville, NC 27028) and ALEX RANDALL GRUBB (Grantee
Address: 130 Kent Lane,Mocksville,NC 27028); hereinafter referred to as the GRANTEES;
WITNESSETH:
THE GRANTORS,for valuable consideration paid by the GRANTEES,receipt of which is
acknowledged, have and by these presents do convey unto the GRANTEES in fee simple, all that
certain parcel of land situated (the "property") in Mocksville Township, Davie County, North
Carolina, and more particularly described on attached"Exhibit A."
TO HAVE AND TO HOLD the property and all privileges and appurtenances thereto
belonging to the GRANTEES in fee simple.
THE GRANTORS COVENANT with the GRANTEES,that the GRANTORS are seized of
the property in fee simple,have the right to convey the property in fee simple,that title is marketable
and free and clear of all encumbrances,and that the GRANTORS will warrant and defend the title
against the lawful claims of all persons whomsoever except for the exceptions hereinafter stated.
Title to the property is subject to the following exceptions:
Easements and restrictions of record.
All or a portion of the property herein conveyed includes or X does not include
the primary residence of Grantor.
The terms GRANTORS and GRANTEES as used herein include the masculine and the
feminine,the singular and the plural,as the context requires,and the heirs,successors,and assigns
of the parties hereto.
IN WITNESS WHEREOF,the GRANTORS have hereunto set their hands and seals the
day and year first above written.
GRANTORS:
(SEAL)
Jane B. Whitlock
NORTH CAROLINA
COUNTY OF
I,a Notary Public,of the aforesaid County,do hereby certify that Jane B.Whitlock,Grantor,
personally appeared before me this day and acknowledged the due execution of the foregoing
instrument for the purposes therein expressed.
Witness my hand and Notarial stamp or seal,this_day of August, 2011.
Notary Stamp or Seal:
Signature of Notary Public
Printed Name of Notary Public
My Commission Expires:
EXHIBIT A
BEING KNOWN and designated as Lot No. 8,Block B,of Richardson Estates Subdivision,as set
forth in Plat Book 4,Page 31,Davie County Registry,to which reference is hereby made for a more
particular description.
TOGETHER WITH a septic repair easement and right of ingress and egress across Lot 7,Block B,
of Richardson Estates Subdivision,as set forth in Plat Book 4,Page 31,Davie County Registry,as
is necessary to repair the septic tank located on Lot 8 described herein.
SUBJECT TO easements and restrictions of record.
FOR BACK TITLE,see DB 511,PG 847,Davie County Registry. See also Tax Map H-3-4,Blk
A,Pcl 13, located in Mocksville Township,Davie County,North Carolina.
NTE/TAF
X:/My Files/TAF/Real Est/Whitlock,Jane,Deed to Ashley and Alex
r _
APPLICATION FOR SITE EVALUATIONAMPROVEMENT P
Davie County Health Department
Environmental Health Section . 11997
P.O. Box 848
Mocksville,NC 27028
(704) 634-8760 —t--
****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL
THE REQUIRED INFORMATION IS PROVIDED.
1. Name to be BilledContact Person
Mailing Address 3— n t-E Zh4,-A -renk /n, Home Phone
City/State/Zip mcc hsu /10-- �� �2'X��B' Business Phone S
2. Name on Permit/ATC if Different than Above
Mailing Address City/State/Zip
3. Application For: [ ] Site Evaluation [ ]Improvement Permit&ATC [y-B6th
4. System to Serve: [LpFlouse [ ]Mobile Home [ ]Business [ ]Industry [ ] Other
5. If Residence: #People #Bedrooms_- #Bathrooms ^)Dishwasher[ ]Garbage Disposal
�J 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(gallons per day) '
7. Type of water supply: [ ]County/City V J Vell [ ]Community
8. Do you anticipate additions or expansions of the facility this system is intended to serve? [ ]Yes V rNo
If yes,what type?
EITHER A PLAT OR SITE PLAN
PROPERTY INFORMATIO IRED:***IMPORTANT***A OF THE PROPERTY MUST BE
1'76SUBMITTED WITHLlHqS APPLICATION.
Property Dimensions: WRITE DIRECTIONS(fromocksville)TO PROPERTY:
Tax Office PIN: #5-N 9_-/' _-1/
Property Address: Road NameTG//�/ 2i/� V
City/Zip ,�z&-Z/Z Z4L ; T1= -Ag
If in Subdivision provide information,as follows: !?I✓ L7� �!'► (��'k'r
Name: CL=&n/ STrS'
Section: Lot#: ;
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. I, 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 -Aq conduct all testing procedures as necessary to determine the site suitability.
DATE ' ? SIGNATURE `
Revised DCHD(06-96)
THIS AREA MAY BE USED FOR DRAIVINC7 YOUR SITE FLAN:
• , DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section SECTION LOT
Soil/Site Evaluation
APPLICANT'S NAME 'Ael 'b✓ DATE EVALUATED
PROPOSED FACILITY PROPERTY SIZE J/, r
SUBDIVISION 1` VCS ROAD NAME ] I(5 t•� R-
Water Supply: On-Site Well el Community Public
Evaluation By: Auger Boring L/ Pit Cut
FACTORS 1 2 3 4 5 6 7
Landscape position .L
Sloe%
HORIZON I DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH
Texture group
Consistence ;
Structure IK
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-
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(01-90)
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