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137 Bentbrook Drive Lot 2Davie County, NC Tax Parcel Report Thursday, October 20, 2016 Parcel Number: NCPIN Number: Account Number: Listed Owner 1: Mailing Address 1: City: State: Zip Code: Legal Description: Assessed Acreage: Deed Date: Deed Book ! Page: Plat Book: Plat Page: WAKN11%U-: A'H1\ 1\ IN11-Y1" P_ SUKt✓H Y Parcel lntbrination G806OA0002 Township: Shady Grove 5880101640 Municipality: 55413500 Census Tract: 37059-804 PARKER WILLIAM KENT Voting Precinct: EAST SHADY GROVE PO BOX 306 Planning Jurisdiction: Davie County ADVANCE Zoning Class: DAVIE COUNTY 1-1,R-20 Building Value: Land Value: Total Assessed Value: NC Zoning Overlay: 27006-0000 Voluntary Ag. District: LOT 2 BENTBROOK Fire Response District: 1.00 Elementary School Zone: 11/2003 Middle School Zone: 005240020 Soil Types: 0006 Flood Zone: 112 Watershed Overlay: 218210.00 Outbuilding & Extra Freatures Value: 40000.00 Total Market Value: 274240.00 ADVANCE SHADY GROVE WILLIAM ELLIS PcB2 DAVIE COUNTY 16030.00 274240.00 pv� i All data Is provided as is without warranty or guarantee of any kind either expressed or implied including but not limited to the 9 �Davie County, i implied warranties of merchantability or fitness for a particular use. All users of Davie County's GIS website shall hold harmless the j� County of Davie, North Carolina, Its agents, consultants, contractors or employees from any and all claims or causes of action due to ��UN4a E NC or arising out of the use or inability to use the GIS data provided by this website. DAVIE COUNTY HEALTH DEPARTMENT Jt— Environmental —Environmental Health Section !/ • P. O. Box 848/210 Hospital Street • Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990002987 Tax PIN/EH #: 5880-10-1640.KP Billed To: Kent Parker Subdivision Info: Bentbrook Lot # 2 Reference Name: Location/Address: Bentbrook Drive -27006 Proposed Facility: Residence Property Size: see map ATC Number: 3621 **NOTE** This Improvement/Operation Permit DOES NOT authorize the construction of a septic tank system or any wastewater system. An AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION must be obtained from this Department prior to the construction/installation of a system or the issuance of a building permit (in compliance with Article 1 I of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems). THIS PERMIT IS SUBJECT TO REVOCATION IF SITE PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING SYSTEM. Residential Specification: Building Type #People 19 #Bedrooms #BathsQO� Dishwasher: Garbage Disposal: ❑ Washing Machin Basement w/Plumbing: V'-/Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #S11/eats Industrial Waste: Lot Size Type Water Supply Design Wastewater Flow (GPD)�4 0 Site: New;eRepair ❑ System Specifications: Tank Size , rWGAL. Pump Tank GAL. Trench Width Dock Depth Linear Ff\ 1011TI4; Required Site Modifications/Conditions: IMPROVEMENT/OPERATION PERMIT LAYOUT - APPROVED EFFLUENT FILTER RISER(S) IF 6 " BELOW FINISHED GRADE. ****NOTICE: Contact a representative of the Davie County Health Department for final inspection of this system between 8:30 a.m. to 9:30 a.m. or 1:00 p.m. to 1:30 p.m. on the day of installation. Telephone # is (336)751-8760.**** Environmental Health Specialist's Signature: , Date: DCHD 05/99 (Revised) Account #: 990002987 Billed To: Kent Parker Reference Name: rrupuseu raciniy. Mesuaence ATC Number: 3621 DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Tax PIN/EH #: 5880-10-1640.KP Subdivision Info: Bentbrook Lot # 2 Location/Address: Bentbrook Drive -27006 rruNcny Dice: see AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION **NOTE** This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior to issuance of any building permit(s). This Form/Authorization Number should be presented to the Davie County Building Inspections Office when applying for building permit(s) (in compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems). THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTIO IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: Date: CERTIFICATE OF COMPLETION **NOTE** The issuance of this Certificate of Completio 1 indicate the system described on Improvement/Operation Permit has been installed in compliance wit i p er OA, Section .1900 "Sewage Treatment and Disposal Systems," but shall in N W aken a ran th t the system will function satisfactorily for any given period of time. a r 0 Gnr"S`� r - Septic System Installed By: Environmental Health Specialist's Signature: Date: U DCHD 05/99 (Revised) i "Oct 2 11:58a davie county envhealth 336 751 8786 P.2 �i APPUCAI"ION FOR SITE EVALUATION/I41PROVE3I ENT PERMIT & ATC, Davie County Health Department Enrironmente/Health Sec!/on P.O. Box 848/210 Hospital Street Mockeville, He 27028 (336)751-8760 *** THIS APPLICATION CANNOT SE PROCIIS68D UNLESS ALL THS REQUIRED IS PROVIDED. Refer to the INFORXATI0,V BM.LBTIN for inatructions. r Name to be Billed / Mailing Address sO s City/state/ZIPi v Z. Hone on rormit/ASC ie rt!"ar-r tta Nailing Address Contact Person j/J Nome Phonal fal -mess Phone City/Stats/Zip VOZ vim:. Application For$ ❑ Site Evaluation Improvement Permit/ATC ❑ Both �4. System to Service: Q House ❑ Mobile l[o:ne ❑ Business ❑ industry ❑ Other Type system requested$x conv—tioaal ❑ conventional moditied ❑ innovative P (--, b. -21 Reaidsaca$ M People � ti Bedrooms e eattsrnoms _� 6� D0000v iab-sshar 00arbage Disponal asking Maehi o at/Plumbing ❑nasementmo Plumbido 1. rf Business/Iuiustry /other, verity type Y people 0 Stnks 4 Commodes • V=wsrs i urinals A Natar Coolers IF Po0DS8RVICE$ # Seats 8atimated Water Usage (gallons per day) a. 'Type of water supply: Cot:n:.yJCity ❑ Well 17 community �� s. Do you anticipate additions or elpinsions of the facility this system is intended to serve? ❑ Yes QNo If yes, what type? "IMPOR L7ERT5NVH.Q0MF1E7E THE REQUIRED PROPERTY 1NFOWNIATION REQUESTED BELOW.ser a PLAT or SIT], PLA UST BESUBMITTED by the ctient with THIS APPLICATION. !/ Property Dimensions: E DIRE„ IONS (trout Mojk v]Ile) o P PE TY: r Tax Office PIN: `=Y`�J� "j, Tax t. Property Address: RcadName_ �D:. Q w ... City/Zip �le=islonp ovi eioformatio$t,asfoltoars: i_]�*1�r, e a tr Name: Section; Block: — Lot: 0-s- Date home corneas flagged• This is to certify that the Information pr >vided Is correct to the best of my knowledge. I understand that any permit(s) Issued hereafter are subject to suspensic a or revocation, If the site plans or intended use change, or If the Information submitted ht tbis application is falsified ,r changed. 1, also, understand tliat I ain responsible for all charges iucuricd from thisappficadon. [,hereby, give consent +a the Authorized Representative of the Davie County Iierlth 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 suitability. 1 2 s ✓DATEir, , " �/ SIGNATURE THIS AREA 1Y BE USED FOR DIV. WING YOUR SITE PLAN (Include all of the following: Existing a d proposed property lines and dimensions, structur as, setbacks, and septic locations). �i Site Revisit Chorge Client Notification Date: iEHS: Fign glven�� G Account No. Revised DCHD (05/03 Invoice No. I Environmental Health Section P. O. Boz 848/210 Hospital Street MocksN ille, NC 27028 (336)751-8760 INIPROVEMENT/OPERATION PERMIT Account #: 989900195 Billed To: Richard Poindexter Reference Name: Proposed Facility: Residence Tax PIN/EH #: 5880-10-1640 Subdivision Info: Bentbrook Lot # 2 Location/Address: Bentbrook Drive -27006 Property Size: 1 + acre ATC Number: 3331 **NOTE** This Improvement/Operation Permit DOES NOT authorize the construction of a septic tank system or any wastewater system. An AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION must be obtained from this Department prior to the construction/installation of a system or the issuance of a building permit (in compliance with Article 1 l of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems). THIS PERMIT IS SUBJECT TO REVOCATION IF SITE PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING SYSTEM. Residential Specification: Building Type 1-1 oL)�--G- #People #Bedrooms 1- _ #Baths .z• r Dishwasher: 0?""- Garbage Disposal: ❑ Washing Machine: 13 Basement w/Plumbing: ❑ Basement/No Plumbing: P--*' Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size I Type Water Supply C-Z-Ot'j'fYDesign Wastewater Flow (GPD) 4nL Site: New 12r Repair ❑ System Specifications: Tank Size (00CbAL. Pump Tank GAL. Trench Width D Rock Depth 12 Linear Ft. � Other: 1SI �a I nl f.�i7X��S� I 1 U- L P's �t Q.G , 1�--..1ni. �i21 � -'' u Required Site Modifications/Conditions: � �� C�', C.Eji t0L)n . I``ivl IMPROVEMENT/OPERATION PERMIT LAYOUT - APPROVED EFFLUENT FILTER. RISERS) IF 6 " BELOW FINISHED GRADE. ****NOTICE: Contact a representative of the Davie County Health Department for final inspection of this UatQm between -&10 a.m. to 9_3dl.am. or 1:00_g.m--ta.1:30 p.m nn the day .ofin tallation. Telephone # is (336)751-8760.**** �C,(C?) F) LA 6�c 4ot r, Cl t�cJsL. 6. / Environmental Health Specialist's Signature: `J— 1 Pact"• Ll L DCHD 05/99 (Revised) . 41 1 � (1.34A) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boz 848/210 Hospital Street 3 Mocksville NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 989900195 Tax PIN/EH #: 5880-10-1640 Billed To: Richard Poindexter Subdivision Info: Bentbrook Lot # 2 Reference Name: Location/Address: Bentbrook Drive -27006 Proposed Facility: Residence Property Size: 1 + acre ATC Number: 3331 **NOTE** This Improvement/Operation Permit DOES NOT authorize the construction of a septic tank system or any wastewater system. An AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION must be obtained from this Department prior to the construction/installation of a system or the issuance of a building permit (in compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems). THIS PERMIT IS SUBJECT TO REVOCATION IF SITE PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING SYSTEM. Residential Specification: Building Type Hoo -a #People #Bedrooms L— #Baths 2. Dishwasher: 0K'_ Garbage Disposal: ❑ Washing Machine: E Basement w/Plumbing: ❑ Basement/No Plumbing: P*' Commercial Specification: Facility Type #People #People/Shift `'#Seats Industrial Waste: ❑ Lot Size I A' L Type Water Supply ��yDesign Wastewater Flow (GPD) qW Site: New 0`� Repair ❑ r to 1 System Specifications: Tank SizeICX;QAL. PumpTankGAL. Trench Width Rock Depth 12. Linear Ft. Other: LL ��f�i�JT7v.� LAS. HS -1411 t�14ES q,o.e-,. Un,lrJ. Required Site Modifications/Conditions: IMPROVEMENT/OPERATION PERMIT LAYOUT - APPROVED EFFLUENT FILTER RISER(S) IF 6 " BELOW FINISHED GRADE. ****NOTICE: Contact a representative of the Davie County Health Department for final inspection of this Aysiem between -8:30 a.m. to 9.:_ .m. or 1:0 m to 1:30 p.m nn the day7*FEd ion. Telephone # is (336)751-8760.**** iso x, U tJeS i„ 3 04 z coo oJsc aygSmi Uwe Environmental Health Specialist's Signature: DCHD 05/99 (Revised) Lt r� E ' • DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boz 848/210 Hospital Street Moclksville, NC 27028 (336)751-8760 Account #: 989900195 Tax PIN/EH #: 5880-10-1640 Billed To: Richard Poindexter Subdivision Info: Bentbrook Lot # 2 Reference Name: Location/Address: Bentbrook Drive -27006 Proposed Facility: Residence Property Size: 1 + acre ATC Number: 3331 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION **NOTE** This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior to issuance of any building permit(s). This Form/Authorization Number should be presented to the Davie County Building Inspections Office when applying for building permit(s) (in compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Trea ent and Disposal Systems). THIS AUTHORIZATION FOR WASTE ONS IS V LID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature Date: 1�Iq k CERTIFICATE OF COMPLETION **NOTE** The issuance of this Certificate of Completion shall indicate the system described on Improvement/Operation Permit has been installed in compliance with Article I 1 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. Septic System Installed By: Environmental Health Specialist's Signature: DCHD 05/99 (Revised) Date: "I............. .......... ........... ............. ........... ,For . ................. . ......... ...... .......................... g NO . .......... A AV— 'All ............. .......... ........... l,I ................ mmm", ...............""'I M �jigpmw' #ARSI jz pp; 3" qvg; 5N............ S', ........... 5"0,1 l 9 0"',l gpl, ?I ....... j,l ................... ............. gv, MINE' MINN 61i PIN a g,1, limp", . ............ "�.... ..........,� C�I,l, 'l" 'T,g�,;,�!P,��;,��,��:"",��f",�,i",q","f�",k",�F�",,F��j�",!�� .................. .......... .......... A,� lo l,Nlll,Tllq Zi, .................... .......... iAl�o ........ m �'i� NFL IF IN a ioi ........... mhoill' IN ql........... 4 lh ALI, K'il �d C��, 7-*...... 1H U Jig M A Iij4;4 �OU gg, Omm g "%lg, Imm Al `9M l"I'M § �I ;l4i Z 3", IMP lA W ""OMW V N'T, �4 0�&lt oggo lip............. ......... cce APPLICATION FOR SITE EVALUATION/IMPROVEAIENT PERMIT Q • Davie County Health Department Environmental Health Section ��r^ P.O. Box 848/210 Hospital Street 2402 Mocksville, NC 27028'Z'�Q,•^, (336)751-8760 ,,,...,.?rr�`�.► / ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQU INFORMATION IS RROVIDED. Refer to the INFORMATION BULLETIN for instructions. i t / 1. Name to be Billed /("i Mailing Address C City/State/ZIP ,Q 2. Name on Permit/ATC if Different than Mailing Address ✓+7�c0 -c - Contact Person Home Phone 0 Business Phone City/State/Zip 3. Application For: ❑ Site Evaluation lX Improvement Permit/ATC ❑ Both 4. System to service: ) .House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other 5. If Residence: # People # Bedrooms # Bathrooms 4 -kDishwasher ❑ Garbage Disposal 6. If Business/industry/Other: # Commodes ]Washing Machine. ❑ Basement/Plumbing Specify type # Showers # Urinals # People 1y Basement/No Plumbing J # Sinks # water Coolers IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day) 7. Type of water supply: ❑ County/City ❑ Well ❑ Community s. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes �YNo 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: AQ CrPi Tax Office PIN:/� /))b�� z(% �b,?�, Property Address: Road Nam 0/ b//6; City/Zip If in a Subdivision provide information, as follows: Section: Block: Lot: 11 WRITE DIRECTIONS (from Mocksville) to PROPERTY: G.-O'a ,�a �A?, -//"X70/ 2!�2 X-677�-�v,�z 22� ,2ia // la -7' 121 Ze' Date Property Flagged: CJ 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. 1, also, understand that I ant responsible for an 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 to conduct all testing procedures as necessary to determine the site suit DATE �0'S ` o�-' �oZ SIGNATURE J�% �✓ THIS 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). Revised DCHD (07/99) Site Revisit Charge Datc(s): Client Notification Date: EHS: Account No. Invoice No. _ ----- 1 833 I ,3333 9599 -- ..;a��ll�.,-, !i„ €n3;;€"?�;€€€333,q'�✓,q; �,,�;;;;;;;;;;;;;"may 31 jjjj-y,77 L '. i3-:i:";" E� -E 170 (374. ) "f: �/ 33 333333331333333333�3 i3"%"'3% 3 3 / ( ss.,ss z"z ;EEE ,,,,£; R ^K z i 1.37A1 843 9483 :r ,,,,,,; - •,..;.., n3n€n n1313€€311 rrak3km»>rrMva 3 // ! f �//� fi- kE w 3 3 aw3333 E3 3 0/��` E j I t 3 E€1. 3 3 333 k �1 y !/��/ 3/ h .� ♦ .33333 {; 3212"' k✓� s%a'.:^,�' j �!'!� l ///j ,,, s. ,�,��„ f,, ,,3 f 3 „1,.,.331 3 05,;, 3 �..., 3 € '� E„i •►a\• "`3 3 11, 331311”3 s / 11i4371&3f145 9 { x°43111€1 11 „ 8192 / t 3 k ,w } x ! ;F 3k w7+k1.1133k 133 s iaai/ ', ^;,,✓ 7 ,� t - 864'4.uw:'w:ufa' 73 �.. '� E � � � € ��$� 3 3�' �� E f`1 # 1111t1��'�ra 33 E � 1 € 3 SOu7N €a 5 3 H1 ERN RAILROAD -- ---- wwr..„„„ / 3 333 3 3€3 33333k31 3 537 133€ 1 333 €€ f�f 2.35A 2778 3.36A "'�'.•!", .... " € 3 k 1J3 8.87A E 3� 2761 6627' €w �� ' 867E 331i€ 70 w 376 ' 3' �. 2,05 Pl 3 k r` 11kkK 8417 {, t 8438 4y� ik1pd�, E { � 11 ty �-� 397.45 MRP 19 1 3 94 ay 13bo°ti 1.6 1.56A 6912161. 3933 i "�� fl3jI1 �1E 3 91.x', 1 ' 29� 7Z } 3 k1 AS�€E k333��19 }Y 1.62A 7 8 1 `♦87 °39 �R�\ 574 �j3� 3 3 bbb -- 23< �. o- f t - , 7702 j 133 k 1.87A ,5+' 9882 1.44A t 7630 9882 14542 t�is3=H 11 �74} t 3k,k 1 3ti z} 1 N �3k, j€3€law kk3£ 3 3 y PC 9 f � 33k € 3 hkr �, 3 333k 9 3 / r�E ffi 334. ' 1q7 ', ? ✓i/ s ^a '� / 4°� £€ �'Si 333 .......... Yirp,y y w%J".. /;P' r( /w: f "✓ €3i33pii k„fit; €3 // ,3.3..:” 3Y / ;9. r�.v3..., r EEE E313kw3�E 1 E 2336 f f'9 WNMil V 3M -01, 964° " ak1�3-k •_,..-, �/ �f- '/ii- � ;k3,3 ,, ,,,. 3 3,11 33k f 3, ,, - ,3 Xe,„ _.,.�k � ' �33a11k?1313 a€131, ... i/ /fs a, /// oaf 1 v nfkk N9€ 1� � /✓ r r�� 13 3 � ° D � al k 33"vr,('la �J��, _ ' ,•,rw � "" ��`� ��., � ' 9 5•a�`�..... / �;';�.. ..3 53b,-:. " ✓>°/ Erl E € ,1 s .:.,,.. 33 31P>1£/ /3w" / 31iE1� E ! - 3111 - �v r,t 3J31E3J# 3,1 1 f 13 1 s 1 r 1 31 `p E F 13>N'. r3 r � 311 f,fk131,3 k 3,11311 ,y% i� 1fa 9y .Q'7 • 3 1 "133 e31 f' 't2A} 211 33�AMf1€,;; 1 3 61w 3 play v d/'i� s � 1v 3YA /✓ s E1=_.,,� ",. .13 1 3 fE 3 �3 3 tf 1333 J�f'` f g,g <3 33 " (f r 138DA/` -t A331f r111331 ! 31 �/� r x/ + PON 3 h 3 1€333 E 3/- / ;n 3 c 31 ffk/ 913 '9 111 1 3 333k 1k11131 28A1$A.D s'A' EE ''/Tf 33 f1 3 33 . 1E- ,, .- k �kk€ 3 i % 33 3 3 E13g1�'� a/%�/�/� / „. /. 3 lhv w E ' r/ /?I ��77 pp r >3' �w`. 1 /g 3311€��1 w €....3/�� A/ ss APPLICATION FOR SITE EVALUATIONAMPROVEMENTS PERMIT ., Davie County Health Department Environmental Health Section P. O. Box 665 Mocksville, NC 27028 1. Mailing Address 2. Name on Permit if Different than Above Business Phone 3. Application for. General Evaluation a Septic Tank Installa/lon Permit 4. System to Serve: f Houses O Mobile Home O Place of Public Assembly O Business Odustryy / ❑ Other O Unknown S. If house, mobile home: Subdivision5?Ph / ,1_00 Section Lot # 09, No. of People No. of Bedrooms No. of Bathrooms Dwelling Dimensions 6. if business, industry, place of public assembly, other: Specify type No. of People Served No. of Commodes No. of Lavatories No. of Sinks No. of Urinals No. of Water Coolers No. of Showers Water Usage Figures � _ 7. Type of water supply: 0 Public ❑ Private 8. Property Dimensions __,% ��,�� Sewage Disposal Contractor O Basement/Plumbing O Basement/No Plu:,.:,ing O Washing Machine O Dishwasher O Garbage Disposal 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? O Yes O No If yes, what type? O Community '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: This is to certify that the information provided is correct to the best of my knowledge, and I understand 1 am rosponsible for all charges Incurred from this application. DATE CONSE,N EO $SI ,E EVALUATION IQ aE DONE QN ABOVE DESCRIBED PROPERTY MUST CHECK ONE: O 1. 1 OWN the property. ❑ 2. 1 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: 1 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 to conduct all testing procedures as necessary to determine said site's suitability for a ground absorption sewage treatment and disposal system. . DATE SIGNATURE DCHD (11M N DAVIE COUNTY HEALTH DEPARTMENT �e Environmental Health Section Soil/Site Evaluation NAME �'l��ll C,��'G'� DATE EVALUATED ADDRESS PROPERTY SIZE PROPOSED FACIILTY „J`yB�iP LOCATION OF SITE Water Supply: On -Site Well Community Public !i Evaluation By: Auger Boring Pit // Cut FACTORS 1 2 3 4 Landscape position L .L Sloe Z HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH f 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: /'� EVALUATED BY: 'a Z/ LONG-TERM ACCEPTANCE RATE: REMARKS: �i�✓ �� LEGEND Landscave Position (S) PRESENT: 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 :3C -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