252 Bean Road Lot 6Davie County, NC Tax Parcel Report Thursday, November 3, 2016
WARNING: THIS 1S NOT A SURVEY
- Parcel Information
Parcel Number: N600000096 Township:
NCPIN Number: 5745923737 Municipality:
Jerusalem
Account Number:
82529529
Census Tract:
37059-807
Listed Owner 1:
HEWITT ROBERT DONALD JR
Voting Precinct:
JERUSALEM
Mailing Address 1:
252 BEAN ROAD
Planning Jurisdiction:
Davie County
City: MOCKSVILLE
Zoning Class:
DAVIE COUNTY R-20
State:
NC
Zoning Overlay:
DAVIE COUNTY CZOD
Zip Code:
27028-0000
Voluntary Ag, District:
No
Legal Description:
LOT 6 BOXWOOD ACRES
Fire Response District:
JERUSALEM
Assessed Acreage:
5.22
Elementary School Zone: COOLEEMEE
Deed Date:
7/2010
Middle School Zone:
SOUTH DAVIE
Deed Book / Page:
008310839
Soil Types: PaD,PcB2,PcC2,ChA
Plat Book: 0005 Flood Zone:
Plat Page: 137 Watershed Overlay: DAVIE COUNTY
Building Value: 226860.00 Outbuilding & Extra 0.00
Freatures Value:
Land Value: 48040.00 Total Market Value: 274900.00
Total Assessed Value: 274900.00
Davie County,
data Is provided as Is without warranty or guarantee of any Idnd either expressed or implied Including but not limited to the
Implied warranties of merchantability or fitness for a particular use. Ati users of Davie County's GIS website shall hold harmless the
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County of Davie, North Carolina, its agents, consultants, contractors or employees from any and all claims or causes of action due to
or arising out of the use or Inability to use the GIS data provided by this website.
Account M 990002166
Billed To: Melvin Reid
Reference Name:
' DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Boa 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760
,�26-Z 800P Pd,
Tax PIN/EH #: 5745-92-3737.06 MR
Subdivision Info: Boxwood Acres Lot # 6
Location/Address: Bean Road -27028
P.
Proposed Facility: Residence Property Size: 5.22 acres
ATC Number: 2735
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 CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS.
Environmental Health Specialist's Signature: Aeaqe.6n�A' Date: 4-1_
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 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.
a
Septic System Installed By:
Environmental Health Specialist's Signature:
DCHD 05/99 (Revised)
Date: :�e .,j d - % 2
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
' P. O. Bos 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760
IMPROVEMENT/OPERATION PERMIT
Account #. 990002166 Tax PIN/EH #: 5745-92-3737.06 MR
Billed To: Melvin Reid Subdivision Info: Boxwood Acres Lot # 6
Reference Name: Location/Address: Bean Road -27028
Proposed Facility: Residence Property Size: 5.22 acres
ATC Number: 2735
**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 #People_ #Bedrooms 2 #Baths 2_
Dishwasher: El -----Garbage Disposal: ❑
Commercial Specification: Facility Type
Washing Machine: El ----Basement w/Plumbing: ❑ Basement/No Plumbing: ❑
#People #People/Shift #Seats Industrial Waste: ❑
Lot Size d Type Water Supply Design Wastewater Flow (GPD) G o Site: New ft --Repair ❑
System Specifications: Tank Size%O ° ° GAL. Pump Tank ' GAL. Trench Width36 Rock Depth / Z 1� Linear Ft3 J O /
Other:
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.****
14
Environmental Health Specialist's Signature:
DCHD 05/99 (Revised)
�u
Date: O
DAVIE COUNTY HEALTH DEPARTMENT
**Ni3TE'ibinprovement/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 #People _ #Bedrooms r_ #Baths
Dishwasher: d Garbage Disposal: ❑ Washing Machine: d Basement w/Plumbing: ❑ Basement/No Plumbing: ❑
Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑
Lot Size A Type Water Supply Design Wastewater Flow (GPD) ,r'� Site: New Repair ❑
System Specifications: Tank Size % GAL., Pump Tank GAL. Trench Width Rock Depth Linear Ft. 0?4
Other:
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.****
it des tit
9S
Environmental Health Specialist's Signature: Date:
DCHD 05/99 (Revised)
Environmental Health Section
. +
P. O. Boa 848/210 Hospital Street
Mocksville, NC 27028
'
(336)751-8760
IMPROVEMENT/OPERATION PERMIT
Account #:
990001623
��5� Tax PIN/EH #:
5745-92-3737.06
Billed To:T�mmp
Cop�7Subdivision Info:
Boxwood Acres Lot # 6
Reference Name:
'%e�V4v liN1J
Location/Address:
Bean Road -27028 -
Proposed Facility:
Residence
Property Size:
5.22 acres
**Ni3TE'ibinprovement/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 #People _ #Bedrooms r_ #Baths
Dishwasher: d Garbage Disposal: ❑ Washing Machine: d Basement w/Plumbing: ❑ Basement/No Plumbing: ❑
Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑
Lot Size A Type Water Supply Design Wastewater Flow (GPD) ,r'� Site: New Repair ❑
System Specifications: Tank Size % GAL., Pump Tank GAL. Trench Width Rock Depth Linear Ft. 0?4
Other:
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.****
it des tit
9S
Environmental Health Specialist's Signature: Date:
DCHD 05/99 (Revised)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Boz 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760
Account #: 990001623 Tax PIN/EH #: 5745-92-3737.06
Billed To: Tommy Cope Subdivision Info: Boxwood Acres Lot # 6
Reference Name: Location/Address: Bean Road -27028
or.,.,o.+., Qin- 8. 99 aeras
Proposed Facility: Residence. -
ATC Number: 2735
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 WASTEWA CONSTRUCTION IS VXFOR A PERIOD OF FIVE YEARS.
Environmental Health Specialist's Signature: Date:
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 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.
Septic System Installed By:
Environmental Health Specialist's Signature:
DCHD 05/99 (Revised)
Date:
DAVIE COUNTY HEALTH DEPARTMENT
•�` IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTE`Issued in Compliance With Article 11 of G.S. Chapter 130a
S nit ry S wages stems // Permit Number
Name �l� DateN2
6.770
Location - (,�.� ,��~/ ✓ �����1�:�i v� �- ,.�T �,��,�/��
Subdivision Name rl.- Lot No. Sec. or Block No.
w
Lot Size — House 4Z Mobile Home __.._._. Business Speculation
No. Bedrooms_, No, Baths No. in Family.
Garbage Disposal YES 0 NO 2r"
Auto Dish Washer YES NO 0Specification�sofor System:
Auto Wash Maohine YES NO Q
Type Water Supply
APPLICATION FOR SITE EVALUATION/IMPROVEMENT PEIIMIT &
{ Davie County Health Department
Enviro17menta/HeaX1Secti0n
P.O. Box 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760
***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
1. Name to be Billed Me ,li 1 'EL&r -e 9 i�Z_
Contact Person
Mailing Address h( %(f �OJGX/1 / C.
Home Phone % P
�.i 31-14 q 4
City/State/ZIP S / t S KLA+ .�Q
1 ��f Business 76
Y -� Z/4 -41 Z
2. Name on Permit/ATC if Different than Above
sPPhone
( JC.Cic T d �"
3
Mailing Address
City/State/Zip
3. Application For: 9� to Evaluation
@/Improvement Permit/ATC Both
4. System to Service: U /House ❑ Mobile Home
❑ Business ❑ Industry ❑ Other
5. If Residence: # People .3
# Bedrooms
# Bathrooms ^3
�shwasher 4-6krbage Disposal &,Wa'shing Machine ❑ Basement/Plumbing
❑ Basement/No Plumbing
6. If Business/Industry/Other: Specify type # People # Sinks
# Commodes S_ # Showers # Urinals 3 # Water Coolers
IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day)
7. Type of water supply: ❑ County/City ❑ Community
8. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes ❑ No
If yes, what type?
'IMPORTANT' CLIENTS MUST COMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED
BELOW. Either a PLAT or SITE PLAN MUST BESUBMITTED by the client with THIS APPLICATION.
Property Dimensions: cj. L 2•
Tax Office PIN: #-S%,S-% Z- 3 ? 3 ?
Property Address: Road Name N /Lo
City/zip
If in a Subdivision provide information, as follows:
Name:
WRITE DIRECTIONS (from Mocksville) to PROPERTY:
661-A-1600% iV $2,4A.1 RI)
4u 2n/ 11.1', kt X41 o wf Y6u-t-
g1UGIG f Doul -t •2tlS w, -a-
ISL Du,t,�e
Section: Block: Lot: Date Property Flagged: / `-5, /
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 1 an: responsible for all 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 suitability.
DATE 2 /i. d SIGNATURE
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).
Cie_
Revised DCHD 07/99 u—
V
Site Revisit Charge
Date(s):
Client Notification Date:
EHS:
Account No. -5 2►
Invoice No.
INDEXED ON 5745
I 306 I 228 I 223 1
517
039 039
60000009
i.12A
C) co
0841 5.22A 5.18A
3737 5.05A
co 8793
6721
126
S R 1202 340 353
200 260 BEAN ROAD
205
205
Q1
gyp`
6936
5.08A
2727
BEPN '0 301
50 ,99
250
039 0
400
8442
0
9209
0
1231
356
9155
0
9091
400
o-
0
(2.78A)
0759
039
S R 1202
q00 039
N
�
1532
(1.11A)
200
400
a 2
8314
n �J
(3.24A)
O !i
2311
200
m
(16.78A)
N�
(2.98A)
a29
STATE PROJECT
#8.1810201
SHEETS #22,23,24,& 25
•' DAVIE COUNTY HEALTH DEPARTMENT
- Environmental Health Section
Soil/Site Evaluation
APPLICANT INFORMATION
Account #: 990002152
Billed To: Melvin Reid
Reference Name:
Proposed Facility: Residence
Water Supply:
Evaluation By:
On -Site Well
Property Size:
PROPERTY INFORMATION
Tax PIN/EH #: 5745-92-3737.MR
Subdivision Info:
Location/Address: Bean Road -27028
5.22 acres Date Evaluated:
Community
Auger Boring Pit
Public
Cut
FACTORS 1 2 3 4 5 6 7
Landscape position
Slope %
HORIZON I DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON II 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 FP - Flood plain H - Head slope
Texture
S - Sand LS - Loamy sand SL - Sandy loam L - Loam SI - Silt
SICL - Silty clay loam SIL - Silty loam CL - Clay loam SCL - Sandy clay loam
SC - Sandy clay SIC - Silty clay C - Clay
CONSISTENCE
Moist
VFR - Very friable FR - Friable FI - Firm VFI - Very firm EFI - Extremely firm
Wet
NS - Non sticky SS - Slightly sticky S - Sticky VS - Very Sticky
NP - Non plastic SP - Slightly plastic P - Plastic VP - Very plastic
Structure
SC - Single grain M - Massive CR - Crumb GR - Granular ABK - Angular blocky
SBK - Subangular blocky PL - Platy PR - Prismatic
Mineralogy
1:1, 2:1, Mixed
Notes
Horizon depth - In inches
Depth of fill - In inches
Restrictive horizon - Thickness and inches from land surface
Saprolite - S(suitable), U(unsuitable)
Soil wetness - Inches from land surface to free water or inches from land surface to soil colors with chroma 2 or less
Classification - S(suitable), PS(provisionally suitable), U(unsuitable)
LTAR - Long-term acceptance rate - gal/day/ft2
DCHD 05/99 (Revised)
' - APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT &ATC �
Davie County Health Department d
Environmental Healfh Section
P.O. Box 848/210 Hospital Street FEB 2 7 2001
Mocksville, NC 27028
(336) 751-8760 ENVIRONMENTAL HEALTH
DAVIE
***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
1.
Name to be Billed r7W If% % C e
/O
Contact Person
Mailing Address c20P e PW,
Home Phone
�,}
/ �
City/State/ZIP &�iS(�/ l/G � C �Q� p
Business Phone
2.
Name on Permit/ATC if Different than Abo�
e^--�
Mailing Address
City/State/Zip
44,rrLb w i/—,
3.
Application For:-' -mite Evaluation
Improvement Permit/ATC ❑ Both
4.
System to Service: House ❑ Mobile Home
❑ Business ❑ Industry 0 Other
S.
If Residence: # People c
# Bedrooms .3 # Bathrooms
Dishwasher ❑ Garbage Disposal ( Washing Machine O Basement/Plumbing O Basement/No Plumbing
6.
If Business/Industry/Other: Specify type
# People # Sinks
# Commodes # Showers
# Urinals # Water Coolers
IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day)
7.
Type of Water supply: ❑ County/City
A Well ❑ Community
e.
Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes XNo
If yes, what type?
***IMPORTANT*** CLIENTS MUSTCOMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED
BELOW. Either a PLAT or SITE PLAN MUST BESUBMITTED by the client with THIS APPLICATION.
Property Dimensions: 30 X 7G 5- S, as a r.
Tax Office PIN: # 57415, 9 g-3 731,
Property Address: Road Name leal, Rte____
city/zip 1%l0c k3y,'%/ C /V G
If in a Subdivision provide information, as follows:
Name: A X lived' ZD � 6
Section: Block: Lot: 6
WRITE DIRECTIONS (from Mocksville)to//PROPERTY:
Pah �n� ;S, #e
iL"P�<�e
.l�PG/ h iKda�•
Date Property 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 am responsible for all 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 C'oy
to conduct all testing procedures as necessary to determine the site suitability.
DATE- SIGNATURE
SIGNATURE
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
Date(s):
Client Notification Date:
EHS:
Account No. —A 3
Invoice No. CP—/ 6 (P .
274 1.
26 I
2
3737 5.05A
6721
toe//
260
205
I
228
Njk e u
APPI (CATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC
Davie County Health Department D
/*/ E Environmental Health SbWon
P.O. Bos 848/210 Hospital street DEC - 9 10
Mocksville, NC 27028
v, 1336) 751-8760 ENVIRONMENTAL HEALTH
nevir enuem
***n,ZPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED
INFORMATION IS PR(1. //OVIDEDJ/ I a G
. -Rafeer to the INFORMATION BULLETIN for instructions.
1. Wame to be Billed i n 4 a t, l b r o o k=
cc/ntaat Person h -)' n C�a !T a a lb e -o o k
Mailing Address EO Bo x HOLE
T Bo oe Phone X944 -a D - O O
City/State/ZIP Co o l ee m e.e+ NL a -701 y Business Phone 75-1 --5-75
Z. Name on Permit/ATC if Different than Above
Mailing Address
3. Application For: site Evaluation
4. system to service: House 0 Mobile Home
s. If Residence: # People
City/State/Zip
0 Improvement Permit/ATC 0 Both
0 Business 0 Industry ❑ Other
# Bedrooms _ # Bathrooms
0 Dishwasher 0 Garbage Disposal 0 Washing Machine 0 Basement/Plumbing 0 Basement/No Plumbing
6. If Business/Industry/other: Specify type
# Co®modea
# showers
# Urinals
# People # Sinks
# hater Coolers
Ir FOODSERVICE: I Seats Estimated hater Usage (gallons per day)
7. Type of crater supply: ❑ County/City 9 Well ❑ coma►unity
s. Do you anticipate additions or expansions of the facility this system is intended to serve! 0 Yes ❑ No
If yes, what ype?
***IMPIDRTANT*** CLIENTS MUST COMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED
BELOW. Either a PLAT or SITE PLAN MUSTBESUBMITTED by the client with THIS APPLICATION.
Pmperty Dimensions: yaJ ;d WRITE DIRECTIONS (from Mocksville) to PROPERTY:
Tax OMce PIN: # 514 5 a - 3 `7 374ODo,�� a ke � o I s � ba 55 S o l
Property Address: Road Name Lai' 4 (o Bean Rd. i n fec -se-c,+ i o rt 0 CCP p r O X r(e-s .
City/Zip � � � r'1 � d • 1 � 0 `� j�,2. u �' t0 �GtS�"
If in a Subdivision provide information, as follows:' °Zg k a u ; � on r i � h f )
Name:
Section: Block: Lot: _ Date Property Flagged: /,2
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 am responsiblefor all charges incurred form
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,;„�a ({hro ok JRck�e Gvmaaer
to conduct all testingprocedures as necessary to determine the site suitability.
DATE /-2 ' 0 G� 0d SIGNATURE
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 (07/98)
Account No. 30Q
Invoice No. r
'DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P,PPLICANT INFORMATION Soil/Site Evaluation PROPERTY INFORMATION
Account #: 989900300 Tax PIN/EH #: 5745-92-3737.000E
Billed To: Linda Haulbrook Subdivision Info:
Reference Name: Location/Address: Bean Road (Site 6)-27006
PROPOSED FACILITY: W DATE EVALUATED: PROPERTY SIZE: �S✓��
Water Supply: On -Site Well Community Public
Evaluation By: Auger Boring ✓ Pit Cut
FACTORS 1
2 3 4 5 6 7
Landscape position
Slope %
<
HORIZON I DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH
Texture group'
Consistence
/
Structure
Ali
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:
LEGEND
Landscane Position
EVALUATION BY: zeaezl
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
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
tructure
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 (Revised 11/98)
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Environmental Health Section
P. 0. Box 848/210 Hospital Street
Courier 09-40-06
Mocksville. NC 27028
January 8, 1999
Linda Haulbrook
P. O. Box 1104
Cooleemee, NC 27014
Re: Site Evaluation
Bean Road (Site 6)/5.22 Acres
Tax Office PIN: #5745-92-3737
Dear Client(s):
As requested, a representative from this office visited the aforementioned site on
January 6, 1999 Based upon the information provided on the Application for Site
Evaluation and after an evaluation was completed on the site, the site was found to be
provisionally suitable for the installation of an on-site sewage system.
Before an Improvement Permit/Authorization to Construct can be issued the appropriate
application must be filled out and the house/mobile home location staked off.
If you have any questions, please feel free to contact this office.
Sincerely,
Ae�
Robert B. Hall, Jr., R.S.
Environmental Health Specialist
RH/wd
Enclosure(s)