286 Sheffield Farms Trail Lot 11PVNTY HEALTH DEPARTMENT,
�ND (iPtRAT16 PE
EMOlf N' RMITS �:PROPER INF6RMAT16W
APPLICATION FOR SITE EVALUATIONMOROVEMENT PERMIT & ATC
Davie County Health Department
Environmental Health Section
P.O. Box 848
Mocksville, NC 27028 A 2 0 M98
(704) 634-8760
1 WRONMENTAL HEALTH
****IMPORTANT*,*** THIS APPLICATION CANNOT BE PROCESS
THE REQUIRED INFORMATION IS PROVIDED.
1. Name to be Billed ZVohyN e)(ar-tiev- ContactPerson —�-nhy)
MailingAddress HomePhone
44 4 9'01..e I -q� -441-1Q4--% "fo-Lb-9%
City/State/zip Y 1SV) I �q Lz
2. Name o , n PermitIATC if Different than Above. n' �A KCL �—C� r
MailingAddress ( ��rn *r\O City/State/Zip
3. Application For: Site Evaluation Improvement Permit & ATC Both
4. System to Serve: Plfkouse [ ] Mobile Home ] Business ( ] Industry Other
5. If Residence: People -2..; #Bedmoms—�� #Bathrooms �7
[/]Dishwasher[ I Garbage Disposal
Vf Washing Machine [ ]Basement/Plumbing Basement/No Plumbing
If Business/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 D4 Well Community
8. Do you anticipate additions or expansions of the facility this system is intended to serve? Yes No
�If yei, what type?
EITHER A PLAT OR SITE PLAN
PROPERTY INFORMATION REQUIRED: *** IMPORTANT *** AXE=OF THE PROPERTY MUST BE
SUBMITTED WITH TJM APPLICATION.
ruk,
Property Dimensions: 4�05 >( :3 tt() WRITE DIRECTIONS (fro ocksvflle) TO PROPERTY:
Tax Office PIN: # 418-71 I'vi It
Property Address: Road Name 1
City/Zip ry")6r-VSy% �tl :::L-1 Da'T -Rye
If in Subdivision provide information, as follows:
Name: F�r&o
Section: Lot #:
This is to certify that the information provided is correct to the best of my knoWledge.-I understand that any permit(s)
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
y to conduct all testing procedures as necessary to determine the site suitability.
SIG
Revised DCHD (06-96)
THIS AREA MAY BE USED FOR *AWINCI YOUR SITE PLAN:
L;'
e3 ed '4e
rf .e 51
NIP 1
Parcel 12.12
Tax Map F-1
p•S• 186 — 477
1 Charles G. Phelps
o Ln
o
ao
rn
N 87-50"25"E ,1752.25'
446' �
330' /
oQ� �Oc
10 1 � 1Z
E c
N�7.5Ac.
ss .
64 Ac•
0, '7.4 Ac
Ac. o o XX
a n
6
66
65
N 84000'10"W
292.36'
NIP rn
o 04
O ?Q � vii r� •�' , /04 _
C-,!�
4 J
to Cn N In (n
y J
3 0
N
5•'7 Ac 5.5 Ac.
.a
5• c. OD
b �o� m
o
I� I —
s0' acc.aa ea,e,T,.nt
CL existln9 �
NIP 160.26'
326.95' 283.51'
N 81 °22'05"W
S°23 SS, W
r -I—,/ ('ri0ab
,.-
a,
I 14
6.4 Ac
CD
00
10' utility easement a5�
cl Proposed SO' access eosement �0L�' 9� ^�9
��
—352.21'-
10,
352.21'_10' utility easement /\
2 \�
5.7 Ac • \
'7 A c •
S\S8¢- 9'KS 5 _2 18.8860e 185.26 69., 1 . '
_ _3 3 5.8
,
0 _ —06'25W 304.16 BW52'0011W 79°10'
, yL\VIV1%,�
14 DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section SECTION— 4— LOT
Soil/Site Evaluation
APPLICANT' S NAME
PROPOSED FACILITY
SUBDIVISION
DATEEVALUATED
PROPERTYSIZE
ROAD NAME J-5�,Z4,
Water Supply: On -Site Well Community Public
Evaluation By: Auger Boring_ Pit Cut
FACTORS
1 2 3 4 1 5 6 7
Landscape position
Slope %
HORIZON I DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON 11 DEPTH
Texture group
Consistence
Structure
Mineralogy
4,1
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: TION BY
EVALUATION BY
LONG-TERM ACCEPTANCE RATE: OTHER(S) PRESENT:
REMARKS:
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
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 OR - Granular ABK - Angular blocky
SBK - Subangular blocky PL - Platy PR - Prismatic
Mineralo
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 (0140)