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County Line Road Lot 7w �-1 LICATION FOR SITE EA LUATIO'N/IMPROVEMENT PERMIT & ATC Davie County Health Department D - Environmental Health Section P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 ***IM ** TRIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED RMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 1. Name to' be Billed _ )pI1Q R. BRACKEN Contact Person J0w R. 1712f'iW59 Mailing Address JQ0Z SIDES 51 Home Phone 704 Z79`Z50 City/State/ZIP &CKWF-LL Z813A_.. Business Phone 2. Name on Permit/ATC if Different than Above Mailing Address City/State/Zip 3. Application For: WSite Evaluation ❑ Improvement Permit/ATC El Both 4. System to Service: ED/iIouso ❑ Mobile Home ❑ Business ❑ Industry ❑ Other S. Type system requested: conventional ❑ conventional modified ❑ innovative 6. If Residence: �# People 4 # Bedrooms ,3 1 _ # Bathrooms — 13Dishwasher OCarbage Disposal Vashing Machine ❑Basement/Plumbing ❑Basement/No Plumbing 7. If Business/Industry /Other: verify type # People # Sinks # Commodes # Showers # Urinals # Water Coolers IF FOODSERVICE: ii Seats Estimated Water Usage (gallons per day) 8. Type of water supply: e County/City ❑ Well ❑ Community 9. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes EDINo If yes, what type? ***IMPORTANT"°** CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BE SUBMITTED by the client with THIS APPLICATION. Property Dimensions: . 1 X 1100 1 Tax Office PIN: # 4799$ 91s 7 o7 Property Address: Road Name Coyof 1..INE. 1Z�, city/zip ktmoY . u. C. Z%34If - If in a Subdivision provide information, as follows: Name: 75lZ4r—K F2J 9ST. Section: I Block: Lot: W WRITE DIRECTIONS (from Mocksville) to PROPERTY: G4- wcs7 i o N, C. ga I 7n NOV 1-141 2 INTmsr--ago ©E IVOLL 000GON Date home corners flagged: I / `<� A y This is to certify that the information provided is correct to the best of my knowledge. I understand that any pernit(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 Ilds application. I, hereby, give consent to the Authorized Representative of the Davie County IIealth 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 su' ability i DATE �� — �Z s7 _ b Lc SIGNATURE 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). t Sign given Revised DCIID (05/03 Site Revisit Charge Datc(s): Client Notification Date: EHS: Account No. Invoice No. _ APPLICANT INFORMATION Account #: 990003389 Billed To: John Bracken Reference Name: Proposed Facility: Residence Water Supply: On -Site Well DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation PROPERTY INFORMATION Tax PIN/EH #: 4799-86-9137.07 Subdivision Info: Bracken Est Lot # 07 Location/Address: County Line Road -28634 Property Size: see map Date Evaluated: it Z51 Community Evaluation By: Auger Boring Pit Public Cut FACTORS l 2 3 4 5 6 7 Landscape position t_ Sloe % &r2o +5 HORIZON I DEPTH - 20 -1 Texture group Stu, 0— Consistence S Structure Mineralogy HORIZON II DEPTH Texture groupG Consistence F Structure Mineralogy e 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 O• -0• SITE CLASSIFICATION: EVALUATION BY: �ti'�t LA* -J LONG-TERM ACCEPTANCE RATE: /� OTHER(S) PRESENT: REMARKS: " )9_�b- Na 1 ^I A 1 1J�b1`�1 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 05/99 (Revised)