279 IJames Church Road Lot 5Davie County, NC Tax Parcel Report
Wednesday. December 28. 2016
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I I CHURal RD IJAMES CHURCH R6
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287
-295 11
301 243
279 -
AM data is provided as Is without warranty or guarantee of any ldnd either expressed or Implied Including but not limited to the
Davie County, Implied warranties of merchantability or fitness for a particular use. All users of Davie County's GIS website shall hold harmless the
County of Davie, North Carolina, its agents, consultants, contractors or employees from any and an claims or causes of action due to
NCor arising out of the use or lnabft to use the GIS data provided by this website.
WARNING: TIHS IS NOT A SURVEY
Parcel Information
Parcel Number:
G3060B0005
Township:
Mocksville
NCPIN Number:
5820314220
Municipality:
Account Number:
8306172
Census Tract".
37059-806
Listed Owner 1:
MONTEROSSO ANNE M
Voting Precinct: NORTH MOCKSVILLE COUNTY
Mailing Address 1:
279 IJAMES CHURCH ROAD Planning Jurisdiction:
Davie County
City: MOCKSVILLE
Zoning Class:
DAVIE COUNTY R -A
State:
NC
Zoning Overlay:
Zip Code:
27028
Voluntary Ag. District:
No
Legal Description:
LOT 5 FOREST BROOK
Fire Response District:
CENTER
Assessed Acreage:
0.81 Elementary School Zone:
WILLIAM R DAVIE
Deed Date:
3/2016
Middle School Zone:
NORTH DAVIE
Deed Book I Page:
010140579
Soil Types:
PcC2,CeB2
Plat Book:
0006
Flood Zone:
Plat Page:
137
Watershed Overlay:
DAVIE COUNTY
Outbuilding & Extra
Building Value:
Freatures Value:
Land Value:
Total Market Value:
Total Assessed Value:
AM data is provided as Is without warranty or guarantee of any ldnd either expressed or Implied Including but not limited to the
Davie County, Implied warranties of merchantability or fitness for a particular use. All users of Davie County's GIS website shall hold harmless the
County of Davie, North Carolina, its agents, consultants, contractors or employees from any and an claims or causes of action due to
NCor arising out of the use or lnabft to use the GIS data provided by this website.
Account #: 990002095
Billed To: Walter Austin
Reference Name:
Proposed Facility: Residence
ATC Number: 3484
fd 6-3 -01
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. 0. Box 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760
Tax PIN/EH #: 5820-31-4220
Subdivision Info: Forest Brook Lot # 5
Location/Address: Ijames Church Road -27028
Property Size: 1 acre
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 I I of
G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems). THIS
AUTHORIZATION FOR WASTEWATER_C01�4STRUCTION IS VALID FOR A PERIOD OF FIVE YEARS.
Environmental Health Specialist's Signature:_ Date:
KI
CERTIFICATE OF COMPLETION
**NOTE** The issuance of this Certificate of Completion shall.�Iicate the D5=
has been installed in compliance with ArticleALmf-G.S. Cna-pTe'r 130A,
Disposal Systems," but shall in NO WAY be takerk7;z-a��
given period of time.
Septic System Installed By:
is, -
d on Improvement/Operation Permit
.1900 "Sewage Treatment and
n will nction satisfactorily for any
— �P
Date:
Environmental Health Specialist's Signature:
DCHD 05/99 (Revised)
-- Z�
,2'7;2b-�3
DAVIE COUNTY HEALTH DEPARTMENT 3-0 0
Environmental Health Section
P. 0. Box 848/210 Hospital Street
Mocks�ille, NC 27028
(336)751-8760
IMPROVEMENTIOPERATION PERMIT
Account #: 990002095 Tax PIN/EH #: 5820-31-4220
Billed To: Walter Austin Subdivision Info: Forest Brook Lot # 5
Reference Name: Location/Address: Ijames Church Road -27028
Proposed Facility: Residence Property Size: 1 acre
ATC Number: 3484
**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 I I of G.S. Chapter 130A, Wastewater Systems, Section. 1900 Sewage Treatment and Disposal Systems). THIS
PERMIT IS SUBJECT TO REVOCATION IF SM PLANS OR THE INTENDED USE CHANGE. YOUR
WASTEWATER SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING SYSTEM.
Residential Specification: Building Type #People -2 #Bedrooms #13aths
Dishwasher:.0-11, Garbage Disposal: e Washing Machine:-12<*� Basement w/Plumbing: Basement/No Plumbing:
Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste:
Lot Size Type Water Supply Design Wastewater Flow (GPD) Site: Newp0o" Repair 0
System Specifications: Tank Sizela GAL. Pump Tank GAL. Trench Widthr Linear Ft. —?eO
_WRock Depth
Other:
Required Site Modifications/Conditions:
IMPROVEMENT/OPERATION PERMIT LAYOUT - APPROVED EFFLUENT FILTER. RISER(S) IF 6 " BELOW
FINISHEDGRADE. ""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: 110� .0�// Date:
DCHD 05/99 (Revised)
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gloNqENT EQR alTE EVA�U/�TIQN IQ P5 P_QNE QN &BO\� SCRIBED PPOPERTY
_ __ _ __ __ __ _ E jiE -
MUST CHECK ONE: 1-1 1 - I QnN tile propetty. V2. I DO-UQLOW ' N the pro[
If you checked Box #2, tile rest of this form Mtj�j be completed by the owner or a person inuthorizod by tile owner:
I hereby give consent to the authorized representative of the Davie County Health Department to enter upon above dest
property located in Davie County and owned by 1) , kr-' , ,'*')--; q) " r,� ) I _. AN <" --- -
to conduct all testing procedures as necessary to determine said site'j suitability for a ground absorption sewage tre;
and disposal systern.
:2 �� /-, � " e-" .
'218- .
OATE
Dclio (12-90)
0
1.
APPUCATION FOR SITE EVALUATION/IMPROVEM ENT PERMIT
Davie County Health Department
En VMOOIHental llealtll SeCtlOn
P.O. Box 848/210 Hospital Street
Mocksville, NC 27028
(336)751-876V '
JUN 6 2003
EMMONMEIVTAL jE4LT,,
DAVIF[Inon—
***IMPORTANT*** THIS APPLICATION CANNOT BEPROCESSED UNLESS ALL THE REQUIRED----_..
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
' 41'
Name to be Billed 1,JJj411'-'A &
9VS+",r/
Contact Person
Mailing Address 014vi'e &4a&�AV
9W
Home Phone 334- V22-
739-6
City/State/ZIP
TO
Business -Ppp,..
OJ -
b
I N— on Pe -4 +- 1A-rr' 4 f Diffe ren t than Above I,- ) -- - I
17-6,
Mailing Address
3. Application For: 211-ite Evaluation
4. System to Service: a -'House 13 Mobile Home
I "-/' 7- -�)— / 0 'g r
City/State/zip --5 �
13 . Improvement Permit/ATC - 2�'Both
0 Business El Industry 13 Other
5. Type system requested: P"C.-Ventional 0 conventional modified innovative
*1 If Residence: # People # Bedrooms 17 # Bathrooms
M'Dishwasher 26-arbage Disposal Washing Machine OBasement/Plumbing 13Basement/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)
0.11
8. Type of water supply: 2rCounty/City 13 Well 0 Conmunity
9. Do you anticipate additions or expansions of the facility this system is intended to serve? 0 Yes R<"'
If yes, what type?
***IMPORTAN7'k** CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED
BELOW. Either a PLAT or SITE PLAN MUSTBESUBMITTED by the client with THIS APPLICATION.
Property Dimensions: 1,4ewe
Tax Office PIN:# , 03 �=V;z�,O
Property Address: Road . NaZ�4-)— -F Ck - A-
City/Zip
If in a Subdivision provide information, as follows:
Name: ro ?ei
z
Section: Block: Lot:
WRITE DIRECTIONS (from Mocksville) to PROPERTY:
Date home corners flagged:
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 ant responsiblefor all charges incurredfrom
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 suitability.
DATE 4 �-A SIGNATURE 4k��
41 1
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).
ILkt' k-
Sign given
Revised DCHD (05103
Site Revisit Charge
Date(s):
Client Notification Date:
EHS:
Account No.
Invoice No.
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
APPLICAT�T INFORMATION
Account #: 990002095
Billed To: Walter Austin
Reference Name:
Proposed Facility: Residence
Water Supply:
Evaluation By:
On -Site Well
Auger Boring.,
PROPERTY INFORMATION
Tax PIN/EH #: 5820-31-4220
Subdivision Info: Forest Brook Lot # 5
'Location/Address:, Ijames Church Road -27028
Property Size: I acre Date Evaluated: 4�_lj _,9T
Community,
Pit
Public
Cut
FACTORS 1 2 3 4 5 6 7
Landscape position 4__
Slope % I-) —
HORIZON I DEPTH ro r'q
Texture group (7
Consistence
Structure
Mineralogy
HORIZON 11 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:
LONG-TERM ACCEPTANCE RATE:
REMARKS:
EVALUATION BY:
OTHER(S) PRESENT:
LEGEND
Landscape Position
R - Ridge S - Shoulder L - Linear slope FS - Foot slope N - Nose slope
CC - Concave slope CV - Convex slope T - Terrace Fl? - 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)
0
MUSEUM MEMNON MEMEME MOMMEM [AMEMAN ENSUES MEMOS
No
No
V� N x- kfv�� ie, 'r, 4 v —
AUTAW!��IhOlq N6- 17' DAVIE OUNTY HEALTH DEPARTMENT
26
Environmental Health Section PROPERTY INFORMATION.
Permil. e .,P,O. Box 848,
Name !r Mocksville, NC 27028 Subdivision Name:
Phone # 336-751-8760
Directions to property: Section: Lot:
V AUTHORIZATION FOR
WASTEWATER'
Tax Office PIN:#�gv-.J&
SYSTEM CONSTRUCTION
W.. 4
Road Name:
*,*NOTE** This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior
to issuance of any Building Permits. This Form/Authorization Number should be presented to the Davie County Building Inspections
Office when applying for,Building Permits.
(In compliance with Article I I of G.S. Chapter 130A, Wastewater Systems, Section. 1900 Sewage Treatment mid Disposal Systems)
*NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH S;PECI LIST ID'ATEISSUED
Q'�agb„
� �� F •�. �•w tr t L 1 �. .L� '{
1 4QDAVIE. OUNTY HEALTH.DEPARTMENT
TMPR O, EMENT AND OPERATION PERMITS PROPERTY INFORMATION
Pti�Ftee s
w • a
Name,. a •�, � f Subdivision Name:
Directions to property: ��~�fr r ! *�,�f Section: Lot:
\„/ IMPROVEMENT
PERMIT Tax Office PIN.# w- -
Road Name: f�
**NOTE**This Improvement Permit DOES NOT authorize the construction or installation of aseptic 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)
***NOTICE***THIS PERMIT IS SUBJECT TO REVOCATION IF SITE
PLANS OR THE 04TENDED.USE CHANGE.YOUR WASTEWATER'
ENVIRONMENTAL HEALTH"SPEC LIST DATE ISSUED
SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE ;
INSTALLING THE SYSTEM
RESIDENTIAL SPECIFICATION:BUILDING TYPE _ #BEDROOMS #BATHS #OCCUPANTS GARBAGE DISPOSAL:Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLE/SHIFT #SEATS INDUSTRIAL WASTE:Yes or No
LOT SIZE 1 y.TYPE WATER SUPPLY . DESIGN WASTEWATER FLOW(GPD)�l.�D NEW
SITE
REPAIR SITE "
SYSTEM SPECIFICATION .TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH:�.Z LINEAR FT.�
OTHER
REQUIRED.SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT;PERMIT LAYOUT
1 .
{
**CONTACT.A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM
BETWEEN 8:30 9:30 A.M.OR 1:00 1:30 P.M.ON THE DAY OF INSTALLATION.TELEPHONE#IS(336)751=8760.
OPERATION PERMIT
SYSTEM.INSTALLED BY:
AUTHORIZATION NO. OPERATION PERMIT BY: DATE:
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE 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.
DCHD 05/96(Revised).
%
1726 'OUNTY HEALTH,DEPARTME'NT
DAVIE 4.
115� —z,' PROPERTY INFORMATION
IMPROVEMENT AND OPERATION PERMITS
Penr&V
A
:7*
*A _1 �- ,, . �t &U&
Name; Subdivision Name:
Directions to property: Section: Lot:
V IMPROVEMENT
PERMIT' Tax Office PIN:# -S ZZ17
Road Name:
**NOTE** This Improvement Permit DOES NOT authorize the construction or insiallatio�n 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 I I of G.S. Chapter 130A, Wastewater Systems, Section . 1900 Sewage Treatment and Disposal Systems)
***NOTICE*** THIS PERMIT IS SUBJECT TO REVOCATION IF SITE
PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED_' SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE
INSTALLING THE SYSTEM.
RESIDENTIAL SPECIFICATION: BUILDING TYPE # BEDROOMS #BATHS # OCCUPANTS GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE # A-PLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZE /-M-*�';I)TYPE WATER SUPPLY DESfp"�,w
_ASTEWATER FLOW (GPD)�,�,O NEWSITE—Af.—' REPAIRsrm
--GAL. TRENCH WIDTH ROCKDEPTH LINEAR FF.
SYSTEM SPECIFICATIONS: TANK SIZE,&L —GAL. PUMPTANKL ?e -i I..
OT14PR —1
REQUIRED SITE MODIFICATIONS/CONDITIONS-.
IMPROVEMENT PERMIT LAYOUT
C
"CONTACT A REPRESENTATIVE OFTHE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM
BETWEEN 8:30 - 9:30 A.M. OR 1:00( 1:30 P.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (336)751-8760.
OPERATION PERMIT
SYSTEM INSTALLED BY:
AUTHORIZATION NO. OPERATION PERMIT BY: DATE:
"THE ISSUANCE OF THIS OPERATION PERMIT SHA LL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLEDly COMPLrANC,
f_E
WITH ARTICLE 11 OF G.S. CHAPTER 130A, SECTIODi-1900 "SEWAGE TREATMENT AND DISPOSAL SYSTEMS". BUT SHALL IN NO WAY�BE TA16E&' A
GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME.
DCHD 05/96 (Revised)
APPUC41[10N FOR BRE EVALUATION/IMPROWEPAMF PEBMFF & A
Davie County Health Deparftnent
J�
( - En virwimenfal Healift SMWOJ7
P.O. Box 848/2iO Hospital Street Off 2 3 W8
q"el Mocksville, NC 27028
(336)751-8760
M MAL HEALTH
4019
THIS APPLICKTION CaNNOT BE PROCESSED UMMSS kinwu
INFOR14ATION IS PROVIDED. Refer to the IRMPMATION BULLETIN for instructions.
2.
Nam to be Billed T. E. Li 1, / / 1, a M_ --i Contact Person 7,�ya
Mailing Adtiress 776, 6)"A'ams Ra. some Phone (336
qqF-,077/
City/state/zIl? Acloatic-e NC- 2 700 B"Iness Phone _(3310
M- 07a,5
2.
Name on Pe=it/ATC if Different than Above
Mailing Address Clty/State/Zip
3.
Application For: Site ZValuati*.M
a Both
4.
System to Service: House 0 Mobile Home 0 Business 1! 7 7� n4ustry
a other
3.
If Veaida=e: # People # Bedrooms 3 #
Bathrooms Q)la
Dishwasher 13 Garbage Disposal )(Washing Machine 13 BaseMent/Plumbing
11 Basment/Ho Plumbing
6.
If Business/Industry/Other: Specify type # People
# Sinks
# Coumodes # Showers # Urinals # Water -Coolers
IF FOODSERVICE: # Seats Estimated Water Usage (gallons
per day)
7.
Type of water supply: County/city 11 Well
0 Commmity
8.
Do you anticipate additions or expansions of the facility this system Is intended to serve?
0 Yes )(NO
If yes, what type?
***1HP0RFANPft* CLIENTS AIUSTCOMPLETE THE REQUIRED PROPERTY iNFORMATION REQUESTED
.11ELOW. Either a PLAT or SITE PLAN AIUSTRESUBMITTED ky the client with THIS APPUCATION.
Property Dimensions: /00' Xaqt,. c'1 0. J69 0 Acs, wp.m M.. _' . — - -2!6,11
Tax Office PIN: # S06aD'-a0-q17 A +C' T�_SAME_5
�' 600_�6 1 �� � a It r -c_ �"CL
I
Property Address: Road Name CA1111CJ_ 9d'_ 014 Le -P+ L o + -a 5
City/Zlp A ocX-s a i' Ile 1; Al C az,2:�
A8,
If in a Subdivision provide information, as follows:
Name: Fo r es -� I ro n '(-,
Section: Block: Lot: 3
Date Property Maned:
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, aW, understandthat I am raponsiblefor ag charges incurredftom
this appfication. 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 the site suitability.
DATE
THIS AREA MAY BE USED FOR DRAWENG YOUR SffE PLAN (include all of the following: Existing and proposed
property lines and dimensions, structures, setbscla4 and septic locations).
Revised DCHD (07/98)
Account No.
Invoice No.
Ln C)
004 b 0
lop. 40
C$2 CA
4b.
!D
344.58 25.0
(369.56 total) 5 79 39- 0900 w
ca
C'
2530
C-2
Ln
.346.21 25.0
1371.21- total) s 090 03" W O�t
C=
c
5.00
347.57
(372.57 total) S 08* 116'14" W
N 08" 16'14" E 373.56 total
34 8.56
25.00
C=
42
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.:: ) T
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS P, E�141-f [�j r,,' 11
1 0 .
Davie County Health Department
Environmental Heal, ect on
P. 0. Box 665
oc sv e,
r ! 7 : I I
DAVIE COUNTY H'L'.,I-. PI.,
1. Application/Permit Requested By I-) t IDt V,\ INV 11
Mailing Address a I Ro CA (I yy\ () C- � --,, , I I C .
'01
Home* Ph one Business Phone
2. Name on Permit if Different than Above
3. Application/Permit for: General Evaluation
4. System to Serve: House 0 Mobile Home
F'Z� f er�
0 Business D Industry,,,,,,,_ D Oth�
5. If house, mobile home: Subdivision 0 (3
0 Septic Tank Installation
0 Place of Public Assembly
0 Unknown
Section Lot#.
0 Basement/Plumbing
No. of People
0 Basement/No Plumbing
No. of Bedrooms
0 Washing Machine
No. of Bathrooms
0 Dishwasher
Dwelling Dimensions
0 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: VPublic
[I Private
8. Property Dimensions
-Sewage Disposal Contractor
9. Do you anticipate additions/expansion of the facility this sytern is intended to serve? 0 Yes
If vpca whnt Ivnn?
D No
0 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:
IV ra
i) Y- c, , r I- A
nsc- C)(f�
I\ V) � � (� C� �\' J �'k C
14MU4, Cya'J'C'4 atl4aZ,
a-r� P /1�� — 1 -165 (2
I V
0.
ct
This Is to certify that the information provided is correct to tile best of my knowledge, and I understand I am responsible for all charges
I urred from this application.
SIGNATURE
DATE
CONSEN FOR SITE EVAQUATIQN TO BE DONE ON ABOVE PESCRIBED EPOPERTY
MUST CHECK ONE: 0 1. 1 QVLN the property. Pr 2. 1 QQ NOIQVVU the property.
11 you checked Box #2, the rest of this form MQ51 be completed by the owner or a person authorized by the owner:
I hereby give consent to tile authorized representative of the Davie County Health Department to enter upon above described
property located in Davie County and owned by 1�-' V) A
to conduct all testing procedures as necessary to determine said site'A suitability for a ground absorption sewage treatment
and disposal system.
OATE 3!GNATURE
I J I — I _-] —
DCIID (12-90)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section o
Soil/Site Evaluation
NAME DATE EVALUATED
ADDRESS PROPERTY SIZE
PROPOSED FACIILTY LOCATION OF SITE
Water Supply: On -Site Well Community Public
Evaluation By:,;�t_t,-Auger Boring Pit 13 '11% — Cut
FACTORS
1
2 3 4 5 6 7
Landscape position
-05
__5
Slope
HORIZON I DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH
kAft"
WNI,
Texture group
C-1
cl_
Consistence
Structure
Mineralogy
HORIZON III DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
b 5
45 _r
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE'[
SITE CLASSIFICATION: — N EVALUATED BY:
LONG-TERM ACCEPTAN I CE RATE: OTHER(S) PRESENT:
REMARKS: VA :,%� %..� �,
LEGEND
Landscape Position
R -Ridge S7Shoulder 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 ;lay loam- SIL -Silty loam CL -Clay loam SCL-Sandy clay loam
SC -Sandy clay SIC -Silty clay C -Clay
CONSISTENCE
Moist
VFR-V�,-ry 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 OR -Prismatic
Mineraloey
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
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