168 Whitehead Drive Lot 10 Section 2APPLICATION FOR SITE EVALUATION/ IMPROVEMENTS PERMd 9�
Davie County Health Department s�
Environmental Health Section
P. 0. Box 665 r
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
1. Permit Req
2. Address _
Home Phone 9 9e- ��6* 7
_. 7) 2 _ t af..f
3. Property Owner if Different than Above
Address
4. Permit To: a) Install Iter Repair
b) Privy Conventional Other Type
Ground Absorption �
c) Sub -Division �i -MAwr[d 4 k le Sec.'
e� Lot No.
5. System used to serve what type facility: House Mobile Home Business
IndustryOther
b) Number of people
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions-ZJ4='r d A AsI) t) 29 PT
Bed Rooms 3 Bath Rooms ^ �e
Den w/Closet
b) If Business, Industry or Other, State: Number of persons served
What type business, etc.
Estimate amount of waste daily (24 hours)
7. Number and type of water -using fixtures
commodes -:?
lavatory --3
urinals
W
showers D_
garbagedisposal 0
washing machine -
dishwasher sinks
8. a) Type water supply: Public Private Community
b) Has the water supply system been approved? Yes 400F No
9. a) Property Dimensions
b) Land area designated to building site
c) Sewage Disposal Contractor
10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve?
What type?
This is to certify that the information is correct,to,.the best of my k "dge.
Date Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
c
DCHD (6-82)
r DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. 0. Box 665
Mocksville, N.C. 27028
\SOIL/SITE EVALUATION
Name d b N � '�k'z-A'N Wy u Date
Address Lot Size '
CA!`rn0c AREA i AREA 9 ARFA 3 AREA A
Topography/ Landscape Position
S
PS
A:�'P$
S
!) Soil Texture (12-36 in.) Sandy,
Loamy, Clayey, (note 2:1 Clay)
S
PSPS
S
S
U
1) Soil Structure (12-36 in.) �
Clayey Soils
S
eS
S
PS
S
I S�
U
Soil Depth (inches)
St)
_... S
U
PS
U
Soil Drainage: Internal
S
S
-
(:Z�
U
External
S
S
PSS
c
S
PS
U
S
PS
U
i) Restrictive Horizonst'
�j
Ll 01
Available Space
PS
S
PS
U
epE
U
PS
!) Other (Specify)
S
PS
S
PS
S
PS
S
PS
U
U
1) Site Classification
S
U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable
Recommendations/ Comments:
Described by �- Title Date y
SITE DIAGRAM
DCHD (6-82)
DAVIE; COUidTY HEALTH DEPARTM14T
PERCOLATION TEST RESULTS
DATE -io - 11
e A`
tA-
X, K�
C S%GPiPK �/iyytic.l o u„,t1
HAMS Hubbard Realty(Sellin Agent)
( -r Gouty
LOCATION GreenwoodLakes Lot J'°10 Block 8, Whitehead Drive
LOT DIAGIMM
HOLE 140.
2
4
5
6
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Investigation of Greenwood Lakes Subdivision (Cont.)
Page 2 -
August 29, 1979
Lot No. 10, Block 8, has an area of approximately 1 acre and fronts on Whitehead Drive
to the west. Percolation rates, as determined by the Davie County Health Department,
were all greater than 300 mpi. The southwest corner of this property is located in a
depression and is subject to standing water during the wet season. Based on examination
of soil test pits and auger borings on this property, approximately 0.2 ft. of topsoil
overlies a silty clay subsoil to a depth of approximately 1.6 ft. below the existing
grade. This subsoil has a weak, subangular blocky structure and is very slowly permeable
and overlies a massive saprolite that varies in color from reddish -brown to tan and gray.
While the overlying subsoil has a weak, subangular blocky structure, the underlying
saprolite parent rock material is somewhat massive and relatively impermeable, thus
a perched water table condition would exist during the wet season.
Lased on Lhe above noted observations, this site is properly classified unsuitable
for the installation of a conventional sewage disposal system due to the slow soil
permeability, shallow depth to massive saprolite,and seasonally perched water table.
r
APPLICATION FOR SITE EVALUATION/ IMPROVEMENTS. PERMIT
Davie County Health Department
Environmental Health Section
P. 0. Box 665
Mocksville, N.C. 27028 RECENED Q CT O a
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Z. Home Phone 7_2
1. -Permit Requested By Business Phone y
2. AddressO oZ D
3. Property Owner if Different than Above l /
Address
ll /l
4. Permit To: a) Install Alter Repair
b) Privy Conventional Other Type
—
Ground "Absorption
c) Sub -Division 2!3e K Lot No. 10
5. System used to serve what type facility: House Mobile Home Business
Industry Other
b) Number of people
6. ap If house or mobile home, state. size of home and number of rooms.
House Dimensions 3 ! O %C Sa ^ $/I
Bed Rooms_ Bath Rooms a Den w/Closet
b) If Business, Industry or Other, State: N tuber of persons served A
What type business, etc.
Estimate amount of waste daily (24 hours)---
7.
ours) 7. Number and type of water -using fixtures:
commodes 2 urinals garbage disposal l
lavatory showers A washing machine
dishwasher % sinks 3
8. a) Type water supply: Public Private C mmunity�
b) Has the water supply system been approved? Yesl No
9. a) Property Dimensions A99.6 2 I, /Sol L7 , .233.63
b) Land area designated to building site
c) Sewage Disposal Contractor
10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve? NO
What type?
This is to certify that the information is correct to the best of my knowledge.
Date Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
Jet ,-rA eft.
DCHD (6-82)
DAVIE COUNTY HEALTH DEPARTMENT
ENVIRONMENTAL HEALTH SECTION
SITE EVALUATION CONSENT FORM
1. Complete the form below and return to the Davie County Health Department.
2. Carefully follow the procedures as outlined in the enclosed "Information Bulletin."
NOTE: THE ABOVE MUST BE COMPLETED BEFORE A SANITARIAN WILL BE ABLE TO
BEGIN THE REQUESTED EVALUATION.
DETACH HERE AND RETURN TO: Davie County Health Department, Environmental
Health Section, P. 0. Box 665, Mocksville, N.C. 27028
Davie County Health Department
Environmental Health Section
Site Evaluation Consent Form
LOCATION OF PROPERTY: DATE RECEIVED
j.mac, /0 .M4A� . (office use only)
no 1. 1 am the owner of the above described property.
yes no 2. 1 am not the owner of the above described property, however, I certify that I
have consent from , owner to obtain a
owner's name
site evaluation by the Davie County Health Department for the purpose of
determining the suitability for a ground absorption sewage treatment and
disposal system.
ye no 3. 1 hereby give consent to the authorized representative of the Davie County
Health Departmentto enter upon the above described property and conductall
testing procedures as necessary to determine its suitability for a ground
absorption sewage treatment and disposal system.
DATE SIGKATURE
4. 1 hereby authorize the Davie County Health Department to release site
evaluationIts from the above described property to the following:
VOwner
only
Owners designated representative
Anyone requesting results
— Only those listed below
C/-ag--F5
DATE
DCHD (11 /84)
SIGMATURE
E
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name Date to -
Address
o Address `Q Lot Size 9,
FACTORS AREA 1 AREA 2 AREA 3 AREA 4 <:;5)
1)
4
Topography/ Landscape Position
PS � P
_ U U
2) Soil Texture (12-36 in.) Sandy, S S
Loamy, Clayey, (note 2:1 Clay) � C? qg"
3) Soil Structure (12-36 in.) S
Clayey Soils vis CP�' �
U U U
) Soil Depth (inches) PS ' S S
`"—� U"'% 7
U
lJ-
5) Soil Drainage: Internal S
PS bs
U U U
External pS epS�C
U U U
i) Restrictive Horizons
') Available Space S
U U U U
1) Other (Specify) S S S S
PS PS PS PS
U U
i) Site Classification
S
U—UNSUITABLE o .S`—SUITABLE
Recommendations/Comments:
Described by
�Title c
SITE DIAGRAM
DCHD (6-82)
N
PS—Provisionally Suitable
Date _I
U—UNSUITABLE o .S`—SUITABLE
Recommendations/Comments:
Described by
�Title c
SITE DIAGRAM
DCHD (6-82)
N
PS—Provisionally Suitable
Date _I