180 Ginny Lane Lot 16�fy1L APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PER
I f 4 Davie County Health Department o
I,t/J Environmental Health Section Yrte
P. o. Box 665 MAY 2 10
✓moi Mocksville, NC 27028
1. Application/Permit Requested By
Mailing Address"L y YO / 1VQ ✓Y -AL Home Phone
Business Phone
2. Name on Permit if Different than Above cS
3. Application for: 4 General Evaluation ❑ Septic Tank Installation Permit
4. System to Serve: j@7 House
❑ Mobile Home ❑ Place of Public Assembly
❑ Business ❑ Industry / ❑ Other ❑ Unknown
5. If house, mobile home: Subdivision _ ;e2 � 1Jg ol�� P� Section Lot #
No. of People y
No. of Bedrooms J
No. of Bathrooms 2—
Dwelling Dimensions
6. If business, Industry, place of public assembly, other: Specify type
No. of People Served
No. of Commodes —
No. of Lavatories
No. of Showers
No. of Sinks
No. of Urinals
No. of Water Coolers
Water UsageFigures
7. Type of water supply: ❑ Public ❑ Private
8. Property Dimensions 9'�a of aauo Sewage Disposal Contractor
"asement/Plumbing
❑ Basement/No Plumbing
"ashing Machine
O�Dishwasher
❑ Garbage Disposal
9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes ❑ No
If yes, what type?
❑ 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:
OU/1 40 Qovdr tw Dii 4-b
/�`ddle (t t-c/e 4, (2,1, 7 Dile 4-o
��D��✓�r 6/0 Rl% t�'4 369eY ec.-itv 'tS1n-4eSpV
This is to certify that the information provided is correct to the st of my knowledge, and I understand I am responsible for all charges
Incurred from this application.
c1�_-.I- 9
DATE SIGN URE
CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY
MUST CHECK ONE: ❑ 1. 1 OWN the property. 'r `. I DO NOT OWN the property
If you checked Box #2, the rest of this form MUST be completed by the owner or a person authorized by the owner:
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
and disposal system.
t:5`- :�_- 9'S
DATE
DCHD (1193)
...r DAVIE COUNTY HEALTH DEPARTMENT.
Environmental Health Section ;
Soil/Site ,Evaluation '
NAME�]��'�("r/ //�f ��i DATE EVALUATED
ADDRESS- PROPERTY SIZE
PROPOSED FACIILTYLOCATION OF SI TE
Water Supply:
On -Site Well
Community
Public
Evaluation By: _
-. AugerBoringJ,o<
Pit --
Cut -
FACTORS 1 2 3 4
Landscape position. L L
Sloe X
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: �S EVALUATED BY:
LONG-TERM ACCEP ANCE RATE: OTHER(S) PRESENT:
REMARKS:'ye, IQ� IL.Q
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
Mois
VFR- Very friable FR -Friable FI -Finn 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(01-901
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
I
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name
G b Date
Address Lot Size
rA nr^MO eoGe i AREA 9 AREA 3 AREA 4
F
)'Topography/ Landscape Position
PS
S
PS
S
PS
S
PS
U
U
U
U
Soil Texture (12-36 in.) Sandy,S
PS
.
PS
S
PS
S
PS
Loamy, Clayey, (note 2:1 Clay)
U
U
U
U
q Soil Structure (12-36 in,)
PS
S
PS
S
PS
S
PS
Clayey Soils
U
U
U
U
q Soil Depth (inches)
11::�
PS
S
PS
S
PS
S
PS
U
U
U
U
i) Soil Drainage: Internal
r
S
PS
S
PS
S
PS
PS
U
U
U
U
External
S
PS
S
PS
S
PS
U
U
U
U
3) Restrictive Horizons
�-
r) Available Space
S
S
PS
S
PS
S
PS
U
U
U
U
3) Other (Specify)
S
PS
S
PS
S
PS
S
PS
U
U
U
U
3) Site Classification
U-UNSUITABLES—SUITABLE PS—Provisionally Suitable
Recommendations /Comments:
Described by 1Z T1 S . Title Date
SITE DIAGRAM
q�
3ti1V
'as/ • 7f
R/lY
_3
•,�/ A Cl b. IN pq 153 i
J H a N06"03'07"E,
0
37.31 i
- S 7v� ._� '• ONTP.OL COR -
6NER
� al
1� P •' S� 8j°
1601 14
0.60 C. v �40/
f N_86! 17� 16"_ W N w 78 3
---- 4.66 G'TOT
w 225.86 -- p
-, tW 0.841 ACq. v C WILLI
1_ v w'uTILm FaSEMEN7 ) ty: 3 v 1 59 `,q S 86 42�39"E--�35 97 TDB
` 1I
Yn1 `� 2 �o i .� M `" 4 r stone 179.23 TOTAL S 86 4
�JO C) 6 �sA C N 1 10 G G z 3® N 0 CONTROL CORNER 27-18 152.56 175. 0 O i I ° 2' 39" E
J a 0.
1 7 c N � 1� 15.00
�� �, o:7ss Ac. 5 - o. eo7 ac. J,-, 1 W j
175.Oo /
226.84 St\3 �p�� 0 1
p 160.00 z 9U O u t 6 .� 0 w O of ti
i O 614.95 rOTA 175.00 - a
2.'. = ` (PUEI-- N
86- 17, 16" �y 53.11 `� /86 )ro c - Imo` o � ^ � I c - o a
3 STkEET) 3 Q4 -_ n �.� N c
+ 1W GINNY o.00 A ipe { ��1 o Q o o M
�J S E6° 17' 16" E °� LANE ``d��s /074`SG;}� 0.804 AC- O N a N 0.805 AC. o Ki
13 617.2 2 707A1 N>3°`O r �: z I 0 0.804 A C. C �'
370 2 W SoI� c' z
�z 6v 1 Sd1� z SCI 9
v, 6 r �•rJ, 75.VU 175. r I
Y/IIUAM q E 0 R/W 0 9°r' U>;, =Cos 00 e+ T6 175.00 X42
D.&. 9a aG. LIS - 3.\3 15E.56 �s ° 63.>s
v
Oy a-0/ I? 86-�0 S N 6°4^;1.L., sa rG GINNY LANg Sr- 3�' c2.2i� rJ' iPUELIC -o 6P, \
� l EXISTING �, Z � � `Q�p a �h � S�.cs:.,_-s79�, �__ - a0
413.31 EAc . Q �D � 18 �0 '� � cS ' y 123.06 P
7C'gL-� Eh;ENT o r t 150.00 X66°4� ;�..
S '•� 86`13 3p.. ,� ` Ju.J24 �`' W 1 _ .GO-'�'C�•{fin
86° 13 3 - . AC. - IN _-
R 132.47 5 E 383.56 70, A m N A4° 53''44.' Iy i s..
.H Rh 'L� L Q
8. 40 PC.3Ci 132-47 cw 182.70
I
118 62 V m I W W C W
3 w Q N 0.561 A r ,G , _ _ orf,..
M 22
_" m . 23 = - M is 19 1 16 n 15 -apt o
C_ N C- r, W N n ti N n J 10 C
_yWW 7 _ 14
C;' N H l0 ` I i v, O N •n �' 1 3 M N
is °rtLn n N 84° 53 44"w ; z z z
24 a.19 o to I86.e9 0 937 AC.
.ti:;5;r o C o0.r 901 A 1.012 AC.
0.852 A C.
;... v� ;2 0.768AC. z n �° 561 qC 0.914 AC.
0 21 c I
C rl-
�' - 1o'UTILITY - _ 4 rD i I _151.58_-- ----
185°, c' ^ t0' _ � _ EASEMENT �`� ` 2 v IS G� °- 6� _ 151.58---- -----151.58---- ---
3 56 W +P`j 3.75-18.03- - �J�+ EASEMENT FGi IW
O.ly �_ 1126.34 ---
3 ��� - 132.53-- - :r TEMPORARY CUL-DE-SAC -___121.00---
° 1 193A5 ------ S 65°00 54 W
N 86 02' 255 W N 8 7° 55' 5� L --IIS 07--- 60.94 b. , 4" W i0 UTILIT 10 UTILITY EASEMENT
S 8 OO 5
150.56 TOTAL 490.46 TOTAL ...-
• HEAL S. CORDON
,A;
NEd1`US GORDON o PLAT BK.4 PG. I+
N ns° z�' °.- D;8' 121 PG. 15.,- -
', :. 574
- 4 163
Boger Real Estate
142 Hwy. 801 North
Advance, NC 27006
Re: Site Evaluation
Springdale - Lot 16
Dear Mr. Boger:
As requested, a representative from this office visited the aforementioned
site on May 2, 1995. Based upon the information provided on the application
for site evaluation and after the evaluation was completed, the site was found
to be provisionally suitable for the installation of an on-site sewage disposal
system. ^:
If you have any questions, please feel free to contact this office.
Sincerely,
Robert B. Hall, Jr., R.S.
Environmental Health Section
RH/wd
Enclosure
Address
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
R O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Date
Lot Size
CACTnO42 AREA 1 AREA 9 ARFA 3 AREA A
Topography/ Landscape Position
S
S
S
PS
PS
PS
PS
U
U
U
U
!) Soil Texture (12-36 in.) Sandy,
S
S
S
Loamy, Clayey, (note 2:1 Clay)
PS
PS
PS
PS
U
U
U
U
I) Soil Structure (12-36 in.)
r -c -S-5
S
S
S
Clayey Soils
PS
PS
PS
PS
U
U
U
U
g Soil Depth (inches)
S
S
S
PS
PS
PS
PS
U
U
U
U
i) Soil Drainage: Internal
rcn�>
S
S
S
PS
PS
PS
PS
U
U
U
U
External
r
S
S
S
/e
PS
PS
PS
PS
U
U
U
U
i) Restrictive Horizons
Available Space
S
S
PS
S
PS
S
PS
U
U
U
U
3) Other (Specify)
S
PS
S
PS
S
PS
S
PS
U
U
U
U
9) Site Classification
U—UNSUITABLE Q SUITABLE PS—Provisionally Suitable
Recommendations/Comments:
Described by u� Z.
e s.
Title
SITE DIAGRAM D
1.071t4 /&
DCHD (6-82(
9
Date g— Z "-kr