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124 Chandler Drive Lot 4**NOTE** The issuance of this Operation Permit shall indicate the system described on the ATC 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. System Type:_ S.T. Manufacturer Q t . Tank Date �/ Tank Size Pump Tank Size_ System Installed By: n � ,1j_1 - E.H. Specialist: i11A)ate: GPS Coordinate: FF . I I (I _ a DCHD 11/06 (Revised) DAVIE COUNTY ENVIRONMENTAL HEALTH P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)753-6780 / Fax # (336)753-1680 OPERATION PERMIT Account #: 990005035 Tax PIN/EH #: H519OA0004 Billed To: Paul Seelman Subdivision Info: McAllister Park Lot # Lot # 4 Address: 124 Chandler Drive Location/Address: 124 Chandler Drive -27028 City: Mocksville Property Size: 0.761 Reference Name: Paul & Kathy Seelman Proposed Facility: Expansion **NOTE** The issuance of this Operation Permit shall indicate the system described on the ATC 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. System Type:_ S.T. Manufacturer Q t . Tank Date �/ Tank Size Pump Tank Size_ System Installed By: n � ,1j_1 - E.H. Specialist: i11A)ate: GPS Coordinate: FF . I I (I _ a DCHD 11/06 (Revised) APPLICATION FOR SITE EVALUATION/IAIPROVEA(ENT PERK TC Davie County Health Department DEC Environmenta/Health Section l 6 2004 P.O. Box 848/210 Hospital Street Mocksville, NC 27028 ENVIROIVMEMAt HE (336) 751-8760 DAVIECOUNly ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDIED.JJ Refer to the INFORMATION BULLETIN for instructions. 1. Name to be Billed 1 /l�iar.0 �t �. t -t- Contact Person Mailing Address 61? J-%, Ile�i" Home Phone 777S City/Stato/ZIP /I= (. 27/C j Business Phone 'q6-7-6yc'2-c/ 2. Name on Permit/ATC if Different than Above Mailing Address City/State/Zip � 3. Application For: 0 Site Evaluation ❑ Improvement Permit/ATC ❑ Both 4. System to service: 13 -House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other .5. Type system requested: 13'Convontional ❑ conventional modified ❑ innovative 6. If Residence: # People # Bedrooms 3 ' # Bathrooms {1Dishwasher ❑Garbago Disposal O washing Machina ❑Basement/Plumbing ❑Basement/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) 8. Typo of water supply: 9-eaCounty/City ❑ Well ❑ Community 9. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes 2-N10-- If yes, what type? ***IMPORTANT*** CLIENTS MUST COAIPLETETHE REQUIRED PROPERTY INFORh'IATION REQUESTED BELOIV. Eithcr a PLAT or SITE PLAN MUST BESUBAIITT,ED by the client with THIS APPLICATION. Properly Dimensions: 11'RITC DIRECTIONS (from Alocksville) to PROPERTY: Tax office PIN: #7yi- �.� �:� l �,�` 4o `5e-1 Property Address: Road Name 3 7D DPo it) � c� er� w t� f.1 � � t I.cS`V City/Zip M bi-V-S 6) j' t J L-) A 2 M84 .4,1,j 7 .,tr-C If in a Subdivision provide information, as follows: Name* V4 Section: Block: Lot: Date home corners flagged: 01 LL - This is to certify that the information provided is correct to the best of my knowledge. I understand that any permits) 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 drat I am responsible for all charges incurred from this application. I, hereby, give consent to the Autborized Representative of the Davie County I-Iealtli 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 s�tita ' )ATL SIGNATUItI; TIIIS ARE, 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). Sign given Revised DCIiD (05/03 Site Revisit Charge Datc(s): Client Notification Date: ' EIIS: Account No. Invoice No. IA' 55.0 I' 2,5 A 9 APPLICANT INFORMATION Account #: 989900035 Billed To: Richard Short Reference Name: Proposed Facility: Residence i DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation Property Size PROPERTY INFORMATION Tax PIN/EH #: 5749-63-6844.04 Subdivision Info: Richard Short Lot # 04 Location/Address: Sain Road -27028 5 acres Date Evaluated: Water Supply: On -Site Well Community Evaluation By: Auger Boring Pit Public Cut _ FACTORS Ili,, loll HORIZON I DEPTH Consistencetwo n�4OARAN W—MM-1.10 � HORIZON 11 DEPTH Consistence .: ��-sem HORIZON III DEPTH Consistence Mineralogy HORIZON IV DEPTH Texture roup Consistence �■-�� Mineralogy SOIL WETNESS�o---�� SAPROLITE MAW SITE CLASSIFICATION:_ N LONG-TERM ACCEPTANCE RATE: 0 . REMARKS: LEGEND Landscape Position EVALUATION BY: Z-�* r 004-'� OTHER(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 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) DAVIE COUNT ENVIRONMENTAL HEALTH c P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)753-6780 / Fax # (336)753-1680 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION Account #: 990005035 Billed To: Paul Seelman Reference Fume: Paul & Kathy Seelman Proposed. Facility: Expansion ATC Number: 5838 Tax PIRI H #: H519OA0004 Subdivision Into: McAllister Parts Lot # Lot # 4 Location/Address: -124 Chandler Drive -27028 Property Size: 0.761 a Site Type: ❑New ❑Repair Dl Expansion **NOTE** This Authorization to Construct (ATC) MUST BE ISSUED by the Davie County Environmental Health Section prior to issuance of any building permit(s), (incompliance 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 # Bathrooms # People Basement❑ Basement plumbing❑ Non -Residential Specifications: Facility Type # People # Seats Square Footage(or Dimensions of Facility) Lot Size x ae Type of Water Supply: XCounty/City ❑ Well ❑Community Well System Specifications: Design Wastewater Flow (GPD) 0- Tank Size(o ' VAL. Pump Tank —/— GAL. Trench Width N Max. Trench Depth Rock DepthVX Linear FLAW' 2VIO Site Modifications/Conditions/Other:-cLl Contact the Davie County Environmental Health S6016i 8:30 - 9:30a."n the day of installation. ins ection o this system between e # (336)751 8760. Environmental Health S DCHD 11/06 (Revised) "IMMIli rfil APPLICATION FOR SITE EVALUATIONAMPROVEMENT PERMIT 6 EIVED Davie County Environmental Health C P.O. Box 848/210 Hospital Street NOV 0 7 2011 Mocksville, NC 27028 (336)753-6780/Fax(336)753-1680 Application For: 0 Site Evaluation/improvement Permit ❑ Authorization To Construct (ATC) XBoth Type of Application: ❑New System ❑Repair to Existing System )(Expansion/Modification of Existing System or Facility ***IMPORTANT*** THIS APPLICATION CANNOTBE PROCESSED UNLESS ALL OF THE•REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. A "nT T/` A ATT TATT'1"1T3A A A'MnIO Name 1 ' KL~� S:iQ �LWJ1! Contact Person 2 `3&S -(n?'& (Ni< Address '10 i _+ _ Rmcg- Dr_ . home Phone - 2 2 "�1-0 City/State/ZiP � 1 i r-5 TK '75Z456 Business Phone Name on Permit/ATC if Dif ereni than Above 91A Mailing Address _,City/State/Zip ,_ PROPERTY INFORMATION *Date House/Facility Comers Flagged tXiSf'it q }}tsrry Fr NOTE: A survey plat.or site plan must accompany this application. included: Site Plan OPlat(to scale) (Permit is -valid for 60 months with site plan; no expiration with complete plat.) Owner's Name i Phone Number.Z14 -2W- 90 4 Owner's Address R191es City/State/Zipl(I—, TX 152 Property Address 51e City MOCkGIl llr• Lot SizeT -Rn rcoA * H61gDAo0Oy Subdivision Narnc(if applicable)_ffl_�is}�i�j� _Sectionq ot# Directions To Site: 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 _No jr` 511,- (� C n I t c c: St I»e t� Does the site contain jurisdictional wetlands? _Yes —yNo Are there any easements or right-of-ways on the site? _Yes 4No tt� rtf3t'r Q rQ it! Is the site subject to approval by another public agency? _YesV No Su 4-h rb C�tn� C " Will wastewater other than domestic sewage be generated? Yes'No Shoran an. !stx I y. r>-ieV - IF RESIDENCE FILL OUT THE BOX BELOW # People # Bedrooms Jlf # Bathrooms _ Garden Tub/Whirlpool es Basement: ❑Yes No ilasement Plumbing: []Yes VNo iF NON -RESIDENCE FILL OUT THE BOX BEI,ONV Type of Facility/Business—.-- Total Square Footage of Building # People # Sinks # Commodes i # Showers _ _ _ # Urinals _ Estimated Water Usage (gallons per day) (Attach documentation of similar facility water consumption) FOODSERVICE ONLY: # Seats Type system requested: UConventional Accepted UInnovative UAltemalive I10ther Water Supply Type: County/City Water C New Well ❑Existing Well J Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? U Yes U No Ifycs, 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 detennine compliance with applicable s an ilex. I understand that I am responsible for the proper identification and labeling of property lines and corners and Cl,,oc i flagei or staki g e Ouse/facility location, proposed well location and the location of any other amenities. - Site Revisit Charge ope o% er's or owner's legal repres ntative Signa e cva CDate(,;):_ (�1 ( �'�Gt,�) Client Notification Date:_ �tqi tt,t1 EIIS: Dat �e'r lS1 r-�%L�,C(,F �I�A!.}�l� Sign given 'IXes GNo Q /l/ fl Ji Account # Revised 11/06gV'• Invoice # �0/:3 14 1 -- (n) 210.14 6 � \ ' l � t"��i i � 1 . ✓ ^-cam �— --� ` � r j i � �fw1 I r e� t TOTAL r2 04 PLA +SII .�. ysj}dd 1 [k7F[ � t t i _�•.`,._ � _ _ l r is —'T p- 1 0.02' -L-- i S � S � f �� p cc Lv �✓ �M0 213.4' �f �J 8'x,1 lot Cc, i ON '-y 4.47 �--•--- � as____._,__.._._..___ _ {fit ... - -.. N _ 2: _.r T 20., '\ � d 3 I '"•� � OFF 2114 —.7 .� 1�z..•� / t_.._.__..—.— i=' H5 LOT 54 'SARA HOLLAND 41LL BK 4 FG 48.0 :moi SOP i!":1 •i it r: �''� � jr:2 i _`s ._. i-.. �. E QTEE: r , `3��f'?�7--;.•'�1�; SEE SHEET 2 100 ILAJLL.E� ST All 2110-4 SCALE: 1'=100' . .•.u....; :'c AY,.,::.,•u�-.,_._,.._.xravK�•;.+.iZ91.y._a".v.'iR:k':s7AV�Y47ffiYi�..4_'Y+BPAR;Y_:x^h;;Ri1;:2aZTt's APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC Davie County Environmental Health P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)753-6780/ Fax (336)753-1680 Application For: ❑ Site Evaluation/Improvement Permit ❑ Authorization To Construct (ATC) XBoth 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. APPT.TC'AMT TM1P()PNAATT0M Name Kit Contact Person 2l4 ` 3&1-'(P qed Address r( } Jjr-, Home Phone 21Y4 — Z? 2. "ARD City/State/ZIP Business Phone ;Zj - 5 ` J2 Name on Permit/ATC if Different than Above 91A Mailing Address City/State/Zip PROPERTY INFORMATION *Date House/Facility Corners Flapped tXIS{inct ff m- . L_ NOTE: A survey plat -or site plan must accompany this application. Included: )qSite Plan ❑Plat(to scale) (Permit ifor 60 months with site plan; no expiration with complete plat.) alid Owner's Name Phone Number,21427z= fqo Owner's Address S City/State/ZiphllCs TX 2L41 Property Address pl Lfir Q, City gaou j � Lot Size 0.1 1 Ae, Tom_ 114_rcd A R6_ 1Q0AC0ON Subdivision Name(if applicable) t~,�i �s+r J aAr z Section/Lot# Directions To Site: If the answer to any of the following questions is-"Yes",supporti g documentation must be attached: Are there any existing wastewater systems on the site? tYes _No lie's CLO L�S� I�� • Does the site contain jurisdictional wetlands? _Yes )(_No Via(+fid Are there any easements or right-of-ways on the site? _Yes )(No - Is the site subject to approval by another public agency? _Yes V No Will wastewater other than domestic sewage be generated? _Yes �LNo Shrnarn IF RESIDENCE FILL OUT THE BOX BELOW # People # Bedrooms # Bathrooms _ Garden Tub/Whirlpool ❑Yes Wo Basement: []Yes VNo Basement Plumbing:' ❑Yes VNo 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 XAccepted ❑Innovative ❑Alternative- ❑Other Water Supply Type: County/City Water ❑ New Well ❑Existing Well ❑ Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes If yes, what type? ❑ No 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 s an ules. I understand that I am responsible for the proper identification and labeling of property lines and corners and loc n flaggi or staki g the ouse/facility location, proposed well location and the location of any other amenities. Prope o er's or owner's legal repre ntative sigma a Site Revisit Charge )tSt,V__ Date(s): p (�� )gyp Client Notification Date: Dat G�� `'l��;�nG EHS: :.-� pC� §j o 3S Sign given es ❑No . Account # Revised 11/06161Invoice # r Lu 0. -I C) 2- W 210.14' cot S 2:_W-_ W 6 �01' 0 C4/ - m S 2' W CL rc 37.03' "S 2' 239.17' S 2* 70.78' 103.60' DO' 52' 23' F -7 0. 00' I rot I fV trJ I cr) � :- _ 1111._ _ .1111 oil DE_ V E L 0 P E R R, C. S H 0 R T A iA D `.)36 )407---642 213.9 4' N'__ 2' C 0 CD co co 102.00' TOTAL PLA_ (D 10') 02 Tyr, ON 03 8, w ON < Dt 20" oil DE_ V E L 0 P E R R, C. S H 0 R T A iA D `.)36 )407---642 213.9 4' N'__ 2' C 0 CD co co 102.00' TOTAL PLA_ (D 10') 02 Tyr, ON C'! H5 LOT 59., SARA HOLLAND MLL 8K 4 PG 480 A S S 0 C11 A LS; C. ��S 20" 06 TYF 07 20" OFF SEE SHEET 2 MAIL'Iff')G ADDRESS: 0 100 61118 INIR-LE,, ST 2 ,p5 13' t".. -J 'D !k; {i A LAL I SCALE: 1'=-100' 03 8, w ON < Dt 20" 0 ON I- C'! H5 LOT 59., SARA HOLLAND MLL 8K 4 PG 480 A S S 0 C11 A LS; C. ��S 20" 06 TYF 07 20" OFF SEE SHEET 2 MAIL'Iff')G ADDRESS: 0 100 61118 INIR-LE,, ST 2 ,p5 13' t".. -J 'D !k; {i A LAL I SCALE: 1'=-100' DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT INFO MATION niznnx729ry iivrnnr„rA•rrnXT Account #: 990305035 Tax PIN/EH #: H519UMUO Billed To: Pa I Seelman Subdivision Info: McAllister Park Lot # Lot # 4 Reference Name: PaLl 3roposed Facility: Expansion & Kathy Seelman Location/Address: 124 Chandler Drive -228 Property Size: 0.761 Date Evaluated: 12011 Water Supply: On -Site Well Community Public Evaluation By: Auger Boring__ Pit Cut FACTO S 1 2 3 4 5 6 7 Landscape position F.5 lr Slope % Vb HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON H 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 ACCEPT CE RATE SITE CLASSIFICATIO EVALUATION BY: LONG-TERM ACCEPT CE RATE: OTHER(S) PRESENT: REMARKS: Position LEGEND Landscape R - Ridge S - Should r L - Linear slope FS - Foot slope N - Nose slope CC - Concave slope V - Convex slope T - Terrace FP -Flood plain H - Head slope Texture S - Sand LS - Loam 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 MQiSt VFR - Very friable - Friable FI - Firm VFI - Very firm EFI - Extremely firm 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(�Jnsuitable) Soil wetness -Inches froland 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) T TAR - T.nna-tP.rm arrPnt nrP rate - oatlriaulft') T�nrrr-' nc,nc ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ s■M■■MSM■S■ME■■■■■■■■■■■N■■EEE■■EE■EE■■M/■■■■ MENNENiiiiiim SNEEKIN 00,11T.1100 moriiii ■E■E■EEEE■EEE■IIE■E■■■■■■■■■■�Ittl■■■!1V►1■■■■■■■■■ IEEEEEE■E■E■■M■IIM■Et ii■■_■_■_■_■■■�L*-lIIO■EEE■111\■■ IE■E■■■■■■■■■■�11■■■t..----.—=r.�. ■ICOM■■M■■ImNSII■ ■/■■■O■■■■■■!s'111■■■lii7■/■EE■■E■■IIL"■■■EE■E■■.��i■■ IN■■O■■■■■■■■�\`�!■■■1®M■■■■■■EEE■IIEE�:■■■■■/��%)■■■ ---------------- ■■■■■■■■■■■■■■■■ ■MMMMMM■MMMM■ ■ ■■■MEN■■E■M■■�■ ■ ■ i ■MEEME■ME■E■ ■■■EME■■■E■■ ■M■■E■M■MEO■ ■■■MEMEMEME■ ■M■EM■■■MMO■ ■■■■■MEMS■■ ■EM■OME■■M■ MEMEMMEMMEM ■■MEMEE■■M■ ■■OE■M■EEM■ ONES z Appraisal Card i Page 1 of 1 EELMAN PAUL S & SEELMAN KATHY S NS -190 -AO -004 124 CHANDLER DR UNIQ ID 13391 2527266 BD27-3 ID NO: 5749642125 COUNTY TAX,FIRE TAX CARD NO. 1 of 1 Reval Year: 2009 Tax Year: 2011 LOT 4 MCALLISTER PARK 1.000 LT SRC- Inspection Appraised by 19 on 10/31/2008 06402 MEADOW RIDGE TW -06 C- EX- AT- LAST ACTION 20100922 CONSTRUCTION DETAIL MARKET VALUE DEPRECIATION CORRELATION OF VALUE Foundation - 3 Eff. BASE Standard 10.03000 Continuous Footing 5.0 USE MOD Area UA RATE RCN EYS AYB CREDENCE TO MARKET Sub Floor System - 4 01 1 01 12,5211 174 1120.0613048461200d200d % GOOD 1 97.0 DEPR. BUILDING VALUE - CARD 295,70 Plywood 8.00DEPR. TYPE: Single Family Residential Single Family Residential OB/XF VALUE - CARD 4,41 21 Exterior Walls - MARKET LAND VALUE - CARD 45,00 Face Brick 34.0 STORIES: 2.0 Stories TOTAL MARKET VALUE -GRD 345,11 Roofing Structure - 06 rre utar/Cathedral 13.0 TOTAL APPRAISED VALUE - GRD 345,11 Roofing Cover - 10 Wood Shingle/310 Shingle 6.00 TOTAL APPRAISED VALUE - PARCEL 345,11 Interior Wall Construction - 5 Drywall/Sheetrock 20.00 OTAL PRESENT USE VALUE - PARCEL OTAL VALUE DEFERRED -PARCEL Interior Floor Cover - 12 Hardwood 10.0c TOTAL TAXABLE VALUE - PARCEL 345,11 Interior Floor Cover - 14 Carpet 0.0 - 2 5 - - - + PRIOR i F U S i BUILDING VALUE 236,25 Heating Fuel - 04 Electric 1.00 4 + 6 + BXF VALUE +-16-- + I LAND VALUE 37,50 Heating Type - 10 Heat Pump 4.00 I FOG ++ 1 RESENT USE VALUE 2 I 4 3 DEFERRED VALUE Air Conditioning Type - 03 Central 4.0 0 1 + 1 2 - + TOTAL VALUE 273,750 I 4 + - 1 6 - - + edro0ms/Bathrooms/Half-Bathrooms /3/0 15.00 edrooms AS - 1 FUS - 2 Ll --`O PERMIT CODE I DATE I NOTE I NUMBER AMOUNT athrooms AS -2 FUS - ILL - O 6 W D D 1 ROUT: WTRSHD: +6-+ 0 SALES DATA +-14-+ + - - 2 0 - -+10+ FF. INDICATE I B A S I RECORD DATE DEED SALES 2 I BOOK PAGE M R TYPE /U /I PRICE 2 1 0688 740 11 2006 WD Q I 33800 OTAL POINT VALUE 120.00 BUILDING ADJUSTMENTS ize 3 1 .950 Duality 5 I CUSTM 1.450 Shape/Designj 4 1 FACTOR 4 1.050 OTAL ADJUSTMENT FACTOR 1.45 OTAL QUALITY INDEX 17 I 3 0649 267 2 2006 WD A V I 5 0640 593 12 2005 WD X V ++--20---+ I I FGD 1 I I 3 +8-+ I 2 +12 -+FOP ++ 3 1 +6+ HEATED AREA 2,318 I 0 +---24---+ NOTES SUBAREAUNIT ORIG % ANN DEP % OB/XF DEPR GS ODE DESCRIPTION LTH TH UNIT PRICE COND BLDG#L BAYB EYB RATE V COND VALU 1 225 4.0 10 L 00 200 S 9 441 TYPE AREA - RPL CS 10 ON PAVING BAS 1 49210 17913 OTAL OB XF VALUE 4,410 FGD 552)451 29775 FOG 328 3265 FOP 4 35 1681 FUS 50 9 54627 DO 20 20 4802 FIREPLACE 2 2175 UBAREA I OTALS I3,11 304,84 BUILDING DIMENSIONS BAS=W 1OWDD=N 1OW20S IOE20$ W20N4W6S4W14S22 FGD=W4S23E24N23W20$ E20S 13E 12 FOP=NSEBSSWB$ NSEBS8E6N3E4N35$ PTR=N30 FOG=N20 US=N34E25S11E6S13W12N4W3N6W16$ E16S20W16 S30$. NO INFORMATION IGHEST TMER ADJUSTMENTS TOTAL NO BEST USE LOCAL FRON DEPTH / LND GOND ND NOTES ROA LAND UNIT LAND LINT TOTAL ADJUSTED LAND LAND SE CODE ZONING TAG E DEPTH SIZE MOD FACT RF AC LC TO OT TYPE PRICE UNITS TYP ADJST UNIT PRICE VALUE NOTES FR RES 0100 0 0 1.0000 0 1.0000 45 000.0 1.00 LT 1.00 45,222E 4500 OTAL MARKET LAND DATA 45,00 OTAL PRESENT USE DATA http://maps. co.davie.nc.us/ITSNet/AppraisalCard. aspx?parcel=H519OA0004 10/11/2011 Permitt�_ DAVIE COUNTY HEALTH DEPARTMENT `Name:. UI Sen AAQ Environmental Health Section PROPERTY INFORMATION i 11 - P.O. Box 848 i n '• L .�� Directions to property: "T Mocksville, NC 27028 Subdivision Name: { -t �, �i Si'l11 / Phone #: 336-751-8760 Section: Lot: AUTHORIZATION FOR WASTEWATER Tax Office PIN:# - - SYSTEM CONSTRUCTION-L,'I -L, (ame:Ch" AUTHORIZATION NO: Q I A Road Zip: ZZ OW **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 1 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) _ ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. ENVIRbNMENTAL HEALTH SPECIALIST DATE ISSUED ti RESIDENTIAL SPECIFICATION: BUILDING TYPE N # BEDROOMS . # BATHS # OCCUPANTS ``' GARBAGE DISPOSAL: Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No LOT SIZE TYPE WATER SUPPLY �v u 1170 DESIGN WASTEWATER FLOW (GPD) (� D NEW SITE REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE —r GAL. PUMP TANK --,46hGAL. TRENCH WIDTH G ROCK DEPTH ff/,t LINEAR FT. OTHER REQUIRED SITE MODIFICATIONS/CONDITIONS: N"If' 41 (1-1t IMPROVEMENT PERMIT LAYOUT Y `iir .(1 i(.7 FOR FINAL INSPECTION OF THIS SYSTEM PLEASE CALL BETWEEN 8�:34'1.M„ON THE DAY OF INSTALLATION. TEL PHONE # IS (336) 751-8760. OPERATION PERMIT -----_ I SYSTEM INSTALLED BY: RQ �7 IVI• lie, ,�-p� �, fit,✓, � crudw �b4 lw,t— (,C�L, Yvan- a4 CfA �b b t4* AUTHORIZATION NO. Zg OPERATION PERMIT BY: DATE: Z ADr **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 FF!UNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME. DCHD 02102 (Revised) Psrnutt! 'DAVIE COUNTY HEALTH DEPARTMENT d. yr I pw�jj Environmental Health Section PROPERTY INFORMATION P.O. Box 848 0A I 'Dii4tions to property: Mocksville, NC 27028 Subdivision Name: I Z 1 1-A Phone #: 336-751-8760 Section: Lot: AUTHORIZATION FOR WASTEWATER Tax Office PIN:# SYSTEM CONSTRUCTION ;'l A Road Name: Zip:7-7 07f� AUTHORIZATION NO: 00211 **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 and Disposal Systems) ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. CIV v LAVINIVIZIN J HL nnt%L- I n 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 LOTSIZETYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD) NEW SITE REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE _./�f/� GAL. PUMP TANK ✓&hGAL. TRENCH WIDTH J G ROCK DEPTH LINEAR Fr. IPP REQUIRED SITE MODIFICATIONS/CONDITIONS; IMPROVEMENT PERMIT LAYOUT . J,i � ..,� -51 FOR FINAL INSPECTION OF THIS SYSTEM PLEASE CALL BETWEEN —8:3'6'!:-9,-3aAb/L_0N THE DAY OF INSTALLATION. TEL PHONE # IS (336) 751-8760. OPERATION PERMIT SYSTEM INSTALLED BY: -K kcl I',) Out - 0 a, Z 0 AUTHORIZATION NO. OPERATION PERMIT BY: 11A DATE: V **THE ISSUANCE OF THIS OPERATION PE . RMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE WITH ARTICLE I I 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. DMD 0=2 (Revised) ..—rAlu.4 I / 1 0 5 4 his Q 'S U� Phone: (336) - 751- 8760 Davie County Health Department Environmental Health Section _ P.O. Box 848 210 Hospital Street�� Courier # : 09-40-06 Mocksville, NC 27028 August 21, 2008 Paul Seelman 124 Chandler Drive Mocksville, NC 27028 Re: On-site Sewage System Repair Mr. Seelman: Fax: (336) - 751- 8786 On Wednesday, August 20, 2008 the on-site sewage system serving your residence was repaired by Randy Miller. After discussion on site with Mr. Miller I revised the original repair permit. We had originally planned to cut off the last two lines in the area of where the out building was located. After talking with Mr. Miller and locating the ends of each line, it was determined that the best way to repair would be not to cut off the last two lines, but rather add the 100 feet to the last line. All the lines were full of effluent, thus that told us that the lines that we had thought might be crushed, were not. When testing the last line (by probing) we discovered the effluent discharging into the line was clear. This is an indication that possibly there might be a leak in one or more of the water using fixtures in the residence. I would recommend that the fixtures be checked to make sure that there are no leaks present. The gutter drains on the side of the house need to be piped to discharge past the new line that was added to you existing sewage system. I sincerely hope that this repair will eliminate all your problems you have experienced with -- your on --site wastewater system. Should you have any questions of need any further assistance from this office, feel free to contact us. I am enclosing a copy of the system drawing for you records. Sincerely,, V'I )oe Mando, EH Director CC: Randy Miller •.` DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section �� g P. O. Bog 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Account M 990003524 Tax PIN/EH #: 5749-63-6844.04 Billed To: Greg Parrish Subdivision Info: McAllister Park Lot # 4 Reference Name: Location/Address: Chandler Drive -27028 ATC Number: 4402 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 CONST V DF PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature. ate: CERTIFICATE OF COMPLETIO 2, 7 -gyp **NOTE** The issuance of this Certificate of Completion shall indi tfie syst esc 'bed on Improvement/Operation Permit has been installed in compliance with Article 11 of G. hapter 130A, Section .1900 "Sewage Treatment and Disposal Systems," but shall in NO WAY be taken s uarantee that thh� will function satisfactorily for any given period of time. a 5 �p law• lit Septic System Installed By: Environmental Health Specialist's Signature: Date: DCHD 05/99 (Revised) DAVIE COUNTY HEALTH DEPARTMENT ' r Environmental Health Section P. O. Bog 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 IMPROVEMENT(OPERATION PERMIT Account #: 990003524 Tax PIN/EH #: 5749-63-6844.04 Billed To: Greg Parrish Subdivision Info: McAllister Park Lot # 4 Reference Name: Location/Address: Chandler Drive -27028 Proposed Facility: Residence Property Size: 3/4 acre ATC Number: 4402 **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 1AQL)SE #People #Bedrooms _ #Baths 3 Dishwasher: ❑ Garbage Disposal: ❑ Washing Machine: ❑ Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size Type Water Supply 6DLXAY Design Wastewater Flow (GPD) OltD Site: New 0 Repair ❑ System Specifications: Tank Size ICCO GAL. Pump Tank GAL. Trench Width "Rock Depth N Linear Ft.�l Other:,50 ISTQ 1`CIar.Z 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.**** 5 � I e- EnvirVOlVental Oealth Specialist's Signature: DCHD 05/99 (Revised) L�i DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Bog 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990003524 Tax PIN/EH #: 5749-63-6844.04 Billed To: Greg Parrish Subdivision Info: McAllister Park Lot # 4 Reference Name: Location/Address: Chandler Drive -27028 Proposed Facility: Residence Property Size: 3/4 acre N tuber: 4402 **N0 * is 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 1 DOS #People #Bedrooms ' #Baths 3 Dishwasher: ❑ Garbage Disposal: ❑ Washing Machine: ❑ Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size � A045 Type Water Supplycd;007y Design Wastewater Flow (GPD) �,� Site: New e Repair ❑ System Specifications: Tank SizelCE0 GAL. Pump Tank ICW GAL. Trench Width &N Rock Depth N A► Linear Ft. -_-:Lot Other: 'kT=1r1 t 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.**** -, , r .I. I NJ - wn,,� s 1"i led Awl;a MIA 1f�' oN 5 t 1 �r 4 Elr"onm tal Health Speciali is Signature: ate: DCHD 05/99 (Revised) ".R/W' 20' PAMED PUBLIC RD , P�sl 7) 0 14 5.3 2' 134.170 130.OD' 4m. P"m W* a "I V11 j �.r� �fi 88,00' 44,6.29' N SB' 1' 18- Vil 146.29 m Lo "-j to RN AXLE-. —21.79 .. I 143. 9) TOTAL 2-j ccs 0 0 Ta rl ZE > > M, 0 ri T1 > U) m M ;Z) 0 > > m 146.29 m Lo "-j to RN AXLE-. —21.79 .. I 143. 9) TOTAL 2-j ccs APPLI D 9 200 Appl lett uat DR SITE EVALUATION/IMPROVEMENT PERMIT & ATC Davie County Health Department Environmental Health Section P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760/7Authorization '(336)751-8786 ;ment Permit To Construct ATC ❑ Both Construct(ATC) k- 11 PORTANT*** 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 Contact Person 61" '4r Billing Address / Home Phone - 7 / 13L - City/State/ZIP _ �lP�rr7c.�� rtU C. 77.7/ Business Phone"336 - crU'7-ks%y Name on Permit/ATC if Different than Above Mailing Address PROPERTY INFORMATION Ci NOTE: A surveyplat or site plan must accompany this application. (Permit is valid for 60 months with site plan, no expiration with complete lat.) Street Address fC./ �e?/ 1��! City Lf str, /1�C . Tax PIN# Subdivision Name 1 4c (a- djr '.- ✓.i Section/Lot# y Lot Size To 4- /),1 �l rY- Date House/Facility Corners ,Flagged X S-// -a& If the answer to any of the following questions is "yes", supporting documentation Tust be attached. Are there any existing wastewater systems on the site? Dyes qNo Does the site contain jurisdictional wetlands? Dyes 1310 Are there any easements or right-of-ways on the site? Dyes ', Is the site subject to approval by another public agency? Dyes uwL 690 Will wastewater other than domestic sewage be generated? Dyes IF RESIDENCE FILL OUT THE BO,A BELOW # People ,ie6 , e6 # Bedroo # Bathrooms _� Garden Tub/Whirlpool Dyes DW Basement: ❑Yes F o Basement Plumbing: ❑Yes 9 o' 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: Ceonventional ❑Accepted ❑Innovative ❑Alternative ❑Other. Water Supply Type: U116ounty/City Water ❑ New Well ❑Existing Well ❑ Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes If yes, what type? Fem 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 understand that 1 am responsible for all charges incurred from this application. 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 on the above described property located in Davie Couhty and owned by r% s or owner's legal representative signature Date ti Sign given Dyes ❑No �,I�o ; Q' Revised 2/06 J N N Site Revisit Charge Date(s): Client Notification Date: EHS: Account # 527 Invoice # APPLICATION FOR SITE EVALUATION/Ih1PROVEMENT PERNIIT (l/� Davie County Health Department E§ V �' EnvironmentaiHeaith Section P.O. Box Mocksvi lle INC Hospital 27028 treat APR 73 2005 (336) 751-8760 fNt/IRON MfNr ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE INFORMATION IS PROVIDED. [1 Refer to the INFORMATION BULLETIN for instructions. 1. Name to be Billed �L:-lu••`z/C�9 �p r� Contact Person Mailing Address �// �� / / ! LE'_ f' �S'�' Home Phone %�—� '/f� -�- "7S- City/State/ZIP ti, kS'r�'r� c y �1�'� -47/6_} Business Phone �d -' 6C/ 2. Name on Permit/ATC if Different than Above Mailing Address City/State/Zip 3. Application For: C3''iite Evaluation ❑ Improvement Permit/ATC ❑ Both 4. System to Service: 2 -House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other 5. Type system requested: 0 Conventional ❑ conventional modified ❑ innovative 6. If Residence: # People ? # Bedrooms ,..,� � , � - � # Bathrooms l3Dis2iwasher ❑Garbage Disposal C69a0ahing Machine ❑Basement/Plumbing ❑Basement/No Plumbing 7. If Businoss/Industry /other: verify type # People # Sinks # Commodes # Showers # Urinals t) Water Coolers IF FOODSERVICE: #��Seea�ats Estimated Water Usage (gallons per day) 8. Type of water supply: IIJ'County/City ❑ Well ❑ Community 9. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes ❑-No If yes, what type? ***IMPORTANT*** CLIENTS At UST COMPLETE THE REQUIRED PROPERTY INFORIWATION REQUESTED BELOW. Either a PLAT or SITE PLAN AlUST l3ESUIlM17-TVD by the client with TIIIS APPLICATION. Property Dimensions: &5 Tax Office PIN: ## Property Address: Road Name <5l4 hJ I �r City/Zip WRITE DIRECTIONS (from Mocksville) to PROPERTY: If in a Subdivision provide information, as follows: Name: M ° f}II jSiler Section: Block: Lot: Date home corners flagged: This is to certify that the information provided is correct to the best of my knowledge. I understand that any perntit(s) issued hereafter arc 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 lain responsible for all ckaiges hicurreel fronh tris application. I, hereby, give consent to the Authorized 'Representative of the Davie County IIeaIth 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 13 - D SIGNATURE �-'��, 1-:5 4. 10, TIIIS AREA MAY BE USED FOR DRANVING YOUR SITE PLAN (Include all of the following: Existing and proposed property lines and dimensions, structures, setbacks, and septic locations). SIgn given--Z\-)D Revised DCIID (05103 Site Revisit Charge Datc(s): Client Notification Date: EIiS: Account No. 9f 7f 00 Invoice No. APPLICANT INFORMATION Account* 989900035 Billed To: Richard Short Reference Name: Proposed Facility: Residence DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation PROPERTY INFORMATION Tax PIN/EH #: 5749-63-6844.04 Subdivision Info: Richard Short Lot # 04 Location/Address: Sain Road -27028 Property Size: Date Evaluated: Li .)Q)Q6 Water Supply: On -Site Well Community Public Evaluation By: Auger Boring Pit Cut ft .,r SITE CLASSIFICATION: 0S EVALUATION BY: �t="'�1��` l LONG-TERM ACCEPTANCE RATE: OTHER(S) PRESENT: REMARKS: Q 193 wr LEGEND Landscane 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 Tex ur 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 ois 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 ICI ID 05/99 (Revised) Landscape position HORIZON I DEPTH Consistence HORIZON 11 DEPTH Consistence Structure Mineralogy HORIZON III DEPTH Consistence Mineralogy HORIZON IV DEPTH Consistence SOIL WETNESS SITE CLASSIFICATION: 0S EVALUATION BY: �t="'�1��` l LONG-TERM ACCEPTANCE RATE: OTHER(S) PRESENT: REMARKS: Q 193 wr LEGEND Landscane 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 Tex ur 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 ois 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 ICI ID 05/99 (Revised) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Ptky t 2 SSS Water Supply: On -Site Well Community Public Evaluation By: Auger Boring Pit N� Cut ' • • HORIZON I DEPTH Consistence ORIZON 11 DEPTH HStructure e�■��■�� Consistence r�a�rri�■��■■i�■r WER �M tea`- WW W W:Mem ��■■��s HORIZON III r MNIMS! & ': 0Texture group Min W-AWARM. ml� =1 Consistence Structure OVA IV DEPTH Consistence SOIL WETNESS CLASSIFICATIONHORIZON �r��►�c�aa�� SITE CLASSIFICATION: LONG-TERM ACCEPTANCE RA' REMARKS: EVALUATION BY: 1�F�.�C� 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 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 Dist . 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