131 Sandpit Road Lot 25Au f
fHOR14— NO:&1896; DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section PROPERTY I FORMATION
Permittee's,
P.O. Box 848
Name:. 1 f 'f-7'0 d - Mocksville, NC 27028 Subdivision Name:
/ Phone # 336-751-8760
Directions to pjperty: /„ 1,* Section: /� Lot:
AUTHORIZATION FOR ,
WASTEWATER Tax Office PIN:#!
SYSTEM CONSTRUCTION �t.� .
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
(In. Office when applying for Building Permits.
ompliance with Article, I I of G.S. Chapter 130A, Wastewater Systems, Section.] 900,Sewage Treatment and Disposal Systems)
***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
IS VALID FOR APERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED
APPUCAMON FOR SITE EVAWATION/IMPROVEMENT PERMIT &
Davie County Health Department FJMJ2ffi9 14Envimamenful Health SectionP.O. Box 848/210 Hospital StreetMockaville, NC 27028
(336) 751-8760
rNVIRONLIBITAL HEALTH
***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL
INFORMATION I3 PROVIDED. Refer too the INFORMATION BULLETIN for instructions.
1. Name to be Billed /0C�i��%.Q_ � 64- Contact persons /
Hailing Address
Name Phone 77S(I —,;0 7a2
City/state/zIP (�( NC JV�� Business Phone
2. Name on Perm1t/A1C If Different than Above
Mailing Address
3. Application For: Ll Site Evaluation
City/State/Zip
ovement Permit/ATC
0 Both
4. system to Sergi w: house 0 Mobile Home 0 Business 0 Industry 0 Other
a. If Residence: # People_ I Bedrooms # Bathrooms , 5
�D"s Washer U Garbage Disposal W4zhinq Machine elgi ement/Plumbing 0 Basement/No Plumbing
6. If Business/Industry/other: Specify type # People # Sinks
# Commodes # showers # urinals # Hater Coolers
IF FOODSERVICE: # Seats Estimated Water �Usage (gallons per day)
7. Type of water supply: 0 County/City 0 Community
e. Do you anticipate additions or expansions of the facility this system Is intended to serve? 0 Yes 0 No
If yes, what type'
***IMPDRTANT*** CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED
BELOW. Either a PLAT or SITE PLAN MUST BESURWI TED by the client with THIS APPLICATION.
Property Dimensions: �D 97 CIC .O "vVAF&1 itatECTIONS (from Mochsville) to PROPERTY:
Tax Office PIN: #2/• X0001 —4o -}-D o(-1 'f X t'i-
Property Address: Read N �7iC'/ A%� - 1 A k� p- 1 S+ R O/'1
City/Zip�� �Qn61 Kind � � On
If in a Subdivision provide information, as follows: - t'�'� tQlr G S nJ I i
Name: 1� t�v� ter -.`LS i S Nom? COAST" D /'1 d
Section: Block: Lot: ZSR Date Property Flagged: „ /-/Z -'?/
This is to certify that the information provided is correct to the beat or 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 ! ani responalejor all charges incurred from
this application. 1, hereby, give conseni iu t.`.c A:.:h-crized Renresentstive of the DA -Ale CoonHealth Department
to enter upon above described property located in Davie County and ow74 by DAc-;,AuLhi�-rh
to conduct all testing procedures as necessary to determine the site it h.
DATE /'%/ - 99 SIGNA
THIS AREA MAY BE USEn FOR DRAWING YOUR SITE PLAN (Include all q(tbe following: Existing and proposed
property lines and dimensions, structures, setbacks, and septic locations).
L
Revised DCH9 (07/98)
Account No.
Invoice No.
r
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
NAMEGS
ADDRESS
DATE EVALUATED
PROPERTY SIZE
PROPOSED FACIILTY
%f� { r
LOCATION OF SITE
L
Sloe %
Water Supply:
On -Site Well i
_ Community
Public
Evaluation By:
Auger Boring
Pit
Cut
FACTORS 1
2 3 4
Landscapeposition_______
L
Sloe %
HORIZON I DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH
Texture groupG
Consistence
Structure
Mineralogy
HORIZON III DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION77—
S
LONG-TERM ACCEPTANCE RATE .�
SITE CLASSIFICATION:
LONG-TERM ACCEPTANCER TE:
REMARKS: CJ��I�� f 47
DCHD (01-901
EVALUATED BY: /:�G?
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 ;lay loam- SIL -Silty loam CL -Clay loam SCL-Sandy clay loam
SC -Sandy clay SIC -Silty clay C -Clay
CONSISTENCE
Moist
VFR- Vf:-y friable FR -Friable FI -Firm VFI-Very firm EFI-Extremely firm
Wet
NS -Non sticky SS -Slightly sticky S -Sticky VS -Very Sticky
NP -Non plastic SP -Slightly plastic P -Plastic VP -Very plastic
Structure
3C -Single grain M -Massive CR -Crumb GR -Granular ABK-Angular blocky
SBK-Subangular blocky PL -Platy PR -Prismatic
Mineralogy
1:1, 2:1, Mixed
Notes
Horizon depth - In inches
Depth of fill - In inches
Restrictive horizon - Thickness and inches from land surface
Saprolite - S(suitable), U(unsuitable)
Soil wetness - Inches from land surface to free water or inches from land surface to soil colors
with chroma 2 or less
Classification - S(suitable), PS(provisionally suitable), U(unsuitable)
LTAR - Long-term acceptance rate - gal/day/ft2
r s_ .ten � ��•� r .r . � .rte
,.,r.w�rwr.�w�r •
t7
2.208 Ac.
.-tf m /s —
I
26
g1:892� A�
2s �
HIP
1.9763 Ac. - \
� psf U
-16411- - .0-
N S
2.897
Mor
7;u
09
'COAtfO1 cam[ �6T"+��~ 11 � f Yl� ♦ /f ` 1
2 '�'7 Ac.
2.515 AC. y' 3.436 AC_ .. � o� '
1 2.105 Ac. �I 2-109 A.c. t= `�;^'IIIs
i n !� U
I O
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H ti I �sd ,ssa�
Rd S. R. 143
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