238 Country Cirlce Lot 22Davie Cotintv, NiC
Tax Parcel Report Tuesdav, January 10, 2017
O uu�F All data Is provided as Is without warranty or guarantee of any kind either expressed or Implied Including but not limited to the
Davie County, implied warranties of merchantability or fitness for a particular use. All users of Davie County's GIS website shall hold harmless the
County of Davie, North Carolina, Its agents, consultants, contractors or employees from any and all claims or causes of action due to
npu�N4 NC or arising out of the use or Inability to use the GIS data provided by this website.
WARNING: THIS IS NOT A SURVEY
celInformation
�v
Parcel Number: ._
E814OA0022
Township:
Shady Grove
NCPIN Number: -
5881125527
Municipality:
Account Number:
8306107
Census Tract:
37059-803
Listed Owner 1:
SMITH CASSIEL
Voting Precinct:
EAST SHADY GROVE
Mailing Address 1:
238 COUNTRY CIRCLE
Planning Jurisdiction:
Davie County
City:
ADVANCE
Zoning Class:
DAVIE COUNTY R -A
State: -
NC
Zoning Overlay:
Zip Code:
27006
Voluntary Ag. District:
No
Legal Description:
LOT 22 COUNTRYSIDE SECTION 2
Fire Response District:
ADVANCE
Assessed Acreage:
1.71
Elementary School Zone: SHADY GROVE
Deed Date:
3/2016
Middle School Zone:
WILLIAM ELLIS
Deed Book / Page:
010130034
Soil Types:
GnB2
Plat Book:
0006
Flood Zone:
Plat Page:
014
Watershed Overlay:
DAVIE COUNTY
Outbuilding & Extra
Building Value:
Freatures Value:
Land Value:
Total Market Value:
Total Assessed Value:
O uu�F All data Is provided as Is without warranty or guarantee of any kind either expressed or Implied Including but not limited to the
Davie County, implied warranties of merchantability or fitness for a particular use. All users of Davie County's GIS website shall hold harmless the
County of Davie, North Carolina, Its agents, consultants, contractors or employees from any and all claims or causes of action due to
npu�N4 NC or arising out of the use or Inability to use the GIS data provided by this website.
' OPERATION PERMIT
* Davie County Health Department
210 Hospital Street
P.O. Box 848
Mocksville NC 27028
Phone: 336-753-6780 Fax: 336-753-1680
Applicant: Tamara Smith
Address: 3212 Kensington Place
City: Winston-Salem:
State2ip: NC 27103.
Phone #: (336) 624-3274
rmm
or �ce use �
e/_v
*CDP File Number 200038-1
58841125527
County ID Number,
Evaluated For EXPANSION
Township:.
rproperty Owner: Tamara Smith
Address: 3212 Kensington Place
;City: Winston-Salem
'State/Zip: NC 27103
hone #: (336) 624-3274
Property Location & Site Information
Address/Road #: Subdivision:
Country Side Phase: Lot: 22
238 Country Circle
Nitrification Field
Advance NC 27028
Directions
No. Drain Lines
Structure:— SINGLE FAMILY
1-40 to exit 180A right on Hwy 801 left on Underpass,
Installer: Tim Lawson
Total Trench Length:
right; into Country Circle
1 a ft.
J
# of Bedrooms:" 4
Trench Spacing:
# of People:
*ENS: 2140 -Nations, Robert
*Water Supply: PUBLIC
*IP Issued by. 2140 -Nations, Robert
'System Classification/Description:
- _
TYPE III G. OTHER NON -CONN. TRENCH SYSTEMS
Date: _
*CA issued by: 2140•Nations, Robert
Saprolite System? QYes 9)No
inches
Design Flow: 4-8 8 0 _
* GRAVITY -SERIAL Pump Required?
Distribution Type: QYes.es No
Soil Application Rate: 0 . a 5
*pre Treatment:
Drain field
Nitrification Field
4 8 0 S4• ft.
*System Type: BIDIFUSER STANDARD
No. Drain Lines
1
Installer: Tim Lawson
Total Trench Length:
1
1 a ft.
Certification #: 4952
Trench Spacing:
— 9 Inches O.C. DFeet O.C.
*ENS: 2140 -Nations, Robert
Trench Width:
— 3Oinches
Feet
0 5/ a 7 l a 0 1 6
Date: _
Aggregate Depth:
inches
Minimum Trench Depth: 3
6
.
Inches
Minimum Soil Cover. a
4
Inches
Approval Status
Maximum Trench Depth:3
6
®Approved � D'isapproved
Inches
Maximum Soil Cover: 24
Inches
CDP File Number 200038 -1
Manufacturer.
STB:
Gallons:
Date: J /
*Filter Brand:
ST Marker: ❑ Yes ❑ No
nforced Tank: ❑ Yes -_ ❑ No
1 Piece Tank: ❑ Yes ❑ No
Countv ID Number: 58541125527
)tic TanK
Lat.
Long:
Installer.
Certification #:
*EH S:
Date:
Pump Tank
Installer.
Certification #:
*EH S:
Date:
Manufacturer.
Installer.
PT:
-
Gal Certification #:
Gallons:
inches
*EHS:
Date:
J /
RiserSealed ❑
Yes
❑
No
Date:
Riser Height: ❑
Yes
_ ❑
No (Min.6 in.)
Reinforced Tank: ❑
Yes
❑
No
1 Piece_Tank: ❑_.Yes
.
.: ❑
No
NYE'lo
Apprwaltatus
PVC unions
❑ Yes
Pipe Size:
No
inch diameter
Vent Hole
Pipe Length:
❑
feet
*Schedule:
❑ Yes
0
No
Pressure Rated El
Yes
❑
No
Approved fittings -❑
Yes
❑
No
uppiy Line
Installer:
Certification #:
*EH S:
Date:
f Pump Type:
/
Installer.
Dosing Volume:
-
Gal Certification #:
Draw Down:
inches
*EHS:
*Chain:
J /
Date:
Valves Accessible
❑ Yes
❑
No
Flow Adjustment Valve
❑ Yes
❑
No
Check -valve
El Yes
El
NYE'lo
Apprwaltatus
PVC unions
❑ Yes
❑
No
❑ gppravetl Q = Disapprovetl =
Vent Hole
❑ Yes
❑
No
\ Anti -siphon Hole
❑ Yes
0
No
UP Filq.Number 200038 - I
NEMA 4X Box or Equivalent ❑ Yes
Box 12 inches Above Grade ❑ Yes
Box Adj. To Pump Tank ❑ Yes
Conduit Sealed ❑ Yes
Pump M an ually 0 perable ❑ Yes
*Activation Method:
County ID Number: 58941125527
Electric Equipment
❑ No Installer:
❑
No
Certification #:
❑
No
❑
No 'ENS:
❑
No
Date:
Approval Stafus j
Alarm Audible ❑ Yes ❑ No
O Approvetl❑ Disapproved—
Alarm Visible ❑ Yes ❑ NO _..
2140 - Nations, Robert
*Operation Permit completed by:
00,
Authorized Stat g Date of Issue: 0 5 2 7 1 2 0 1 6
Owner/Applicant Signature:
This system has been installed in with applicable NC General Statutes: Article 11, Chapter 130A, Rules for
Sewage Treatment and Disposal, 15A NCAC 18A.1900 et. Seq.. and all conditions of the Improvement Permit and
Construction Authorization. This property is served by a TYPE III G.
sewage septic system.
TYPE III G.
Rule .1961 requires that a Type septic system meet the following criteria:
Minimum System Review ByThe Local Health Department: N/A
Management Entity: OWNER
Minimum System Inspection/Maintenance Frequency By Certified Operator:
WA
Reporting Frequency By Certified Operator. NIA
Rule .1961 requires that a Type IV and V septic systems designed fora home/business owner must maintain a valid contract
with a public management entitywith a certified operatoror a private certified operator forthe life of the septic system.
Rule .1961 requires that Type VI septic systems designed fora home/business owner must maintain a valid contract with a
public management entity with a certified operator for the life of the septic system.
Rule. 1961 (2) (e) requires a contract shall be executed between the system owner and a management entity prior to the
issuance of an Operation Permit for a system required to be maintained by a public or private management entity, unless the
system ownerand certified operator are the same. The contract shall require specific requirements for maintenance and
operation, responsibilities of the owner and systems operator, provisions that the contract shall be in effect for as long as the
system is in use, and other requirements for the continued proper performance of the system. It shall also be a condition of
the Operation Permit that subsequent owners of the systems execute such a contract.
@Hand Drawing Olmport Drawing
**Site Plan/Drawing attached.**
OPERATION PERMIT
Davie County Health Department
210 Hospital Street
P.O. Box 848
Mocksville NC 27028
Drawing Drawing Type: Operation Permit - -
CDP File Number: 200038 -1
County File Number: 58841125527
Date:
Olnch
Scale: OBlock ft.
ON/A
3
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CONSTRUCTION For Office Use Only
AUTHORIZATION "CDP File Number 200038-1
° = Davie County Health Department County ID Number. 58841125527
210 Hospital Street Evaluated For. EXPANSION
P.O. Box 848 Township:
Mocksville NC 27028 PERMIT VALID UNTIL:
Phone: 336-753-6780 Fax: 336-753-1680 0 a / a 4/ a 0 a 1
Applicant: Tamara Smith Property Owner: Tamara Smith
Address: 3212 Kensington Place Address: 3212 Kensington Place
City: Winston -Salem City: Winston -Salem
State/Zip: NC 27103 State2ip: NC 27103
Phone#: (336) 624-3274 Phone #: (336) 624-3274
Pronerty Location & Site information
(Address/Road #:
238 Country Circle
Advance NC 27028
Structure: SINGLE FAMILY
# of Bedrooms: 4
# of People:
"Water Supply: PUBLIC
Subdivision: Country Side
,`Site Classification: Provisionally Suitable
Saprolite System? OYes QNo
Design Flow: n Q a
Phase: Lot: 22
Directions
1-40 to exit 180A right on Hwy 801 left on Underpass, right
into Country Circle
Minimum Trench Depth: a 4\
Inches
Minimum Soil Cover. 1 a
Inches
Maximum Trench Depth: 3 fi
Inches
Soil Application Rate: 0 - a 5 Maximum Soil Cover: a 4 Inches
*System Classification/Description: "Distribution Type: GRAVITY - SERIAL
TYPE II A. CONV SYSTEM (SINGLE-FAMILY OR 480 GPD OR LESS) Se tic Tank'
"Proposed System: 25% REDUCTION
Nitrification Field
4 8 0 Sq. ft.
No. Drain Lines
Total Trench Length:
Trench Spacing:
Trench Width:
Aggregate Depth:
p Gallons
1 -Piece: OYes ONo
Pump Required: OYes ONo OMay Be Required
Pump Tank: Gallons
1 1-Piece:OYes ONo
1 a 0 ft. GPM -vs— ft. TDH
Q Inches O.C.
9 .j Feet O.C. Dosing Volume: Gallons
QInches
3 a Feet Grease Trap: Gallons
inches Pre Treatment: ONSF OTS -1 OTS -11
Septic Tank Installer Grade Level Required: `01 011 0111 OIV
Dunn d r%f Z
CDP File Number 200038-1 County ID Number. 58841125527
-t 111
❑ Open Pump System Sheet
Kepairbystem Kequired:V TCb l.JNU LJIVU, uur. ndb MVd1ldutC Opdt;C
//Repair System
Trench Spacing:
9 O Inches 0.
*Site Classification: Provisionally Suitable
— W Feet O.C.
Design Flow:
Trench Width:
Inches
3 Feet
4 8 0
_ •
Depth:
SoilAggregate
Application Rate: 0 - a 5
inches
u
Minimum Trench Depth:
a
4
"`System Classification/Description:
Inches
TYPE Il A. CONY SYSTEM (SINGLE-FAMILY OR 480 GPD OR
LESS) Minimum Soil Cover.
1
2
Inches
Maximum Trench Depth:
3
6
"Proposed System: 25% REDUCTION
Inches
Maximum Soil Cover:
a
4
Nitrification Field 1 9 2 0
. Inches
Sq. ft.
No. Drain Lines
"Distribution Type:
GRAVITY - PARALLEL (eq. d -box)
5
Total Trench Length: 4 8 0 ft Pump Required: Oyes ONo OMay Be Required
I\, Pre Treatment: ONSF OTS -1 OTS -II
"Site Modifications
No grading or construction activity is allowed in areas designated for system and repair without approval of Health Department.
"Permit Conditions
The issuance of this permit bythe Health Department in no way guarantees the issuance of other permits. The permit holder
is responsible for checking with appropriate governing bodies in meeting their requirements. ;
This Authorization for Wastewater System Construction shall be valid for a person equal to the period of validity of the improvement Permit, not
to exceed five years, and maybe issued at the same time the Improvement Permit Issued (NGGS 130A-336(11)� If the Installation has not been
completed during the period of validity of the Construction Permit, the information submitted in the application for a permit or Construction
Authorization Is found to have been incorrect, falsified or changed, or the site Is altered, the permit or Construction Authorization shall became
Invalid, and maybe suspended or revoked (.1937(8)). The person owning or controlling the system shall be responsible for assuring compliance
with the laws, rules, and permit conditions regarding system location, Installation, operation, maintenance; monitoring, reporting and repair
(1938(b)).
Applicant/Legal Reps. Signature Required? Oyes ONo
Applicant/Legal Reps. SignatureDate: _ /
"issued By.
Authorized State
2140 - Nations, Robert
Date of Issue: 0 2/.2 4/ 2 0 1 6
----Malfunction Log OYeS
®Hand Drawing Olmport Drawing
**Site Plan/Drawing attached.**
Page 2 of 3
CONSTRUCTION AUTHORIZATION
Davie County Health Department
210 Hospital Street
P.O. Box 848
Mocksville NC 27028
Drawing Drawing Type: Construction Authorization
CDP File Number: 200038 -1
County File Number. 58841125527
Date: 0.1 / 24 / 2 0 1 6
Q Inch
Scale: QBlock
QN/A
r
—/-a
t44
Z�
+I�
CC",
eq
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—/-a
CONSTRUCTION AUTHORIZATION
Davie County Health Department
210 Hospital Street
P.O. Box 848
Mocksville NC 27028
Click below to import an Image from an external location: Drawing
xv�
v 1
CDP File Number: 200038 " 1
County File Number: 58841125527
Date: .0.21 24 I2015
pe: Construction Authorization
ly
o"pPI i C00()
Pee =$1So
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: Xi Site Evaluation/improvement Permit X Authorization To Construct(ATC) X Both
Type of Application: Wew System ❑Repair to Existing System ❑Expansion/Modification of Existing System or at
t
• ***IMPORTANT*** THIS APPLICATION CANNOTBE PROCESSED UNLESS ALL OF THE REQUIRED
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
APPLICANT INFORMATION
Name to be Billed 1 A (ll f lA 'Sl iV 1 Contact Person -Ton a lA Sm i th
Billing Address ' Z 2 ' ncttm p I, Home Phone '!N?�(D –(024 -3211
City/State/ZIP SIV ft&iOf) SQJPAYI JKC, 2-:1101 Business Phone
Name on Permit/ATC if Different than Above.
Mailing Address 20 P7h-C (Q b 1,
iXs5v
�Q�
�� J
PROPERTY INFORMATION *Date House/Facility Comers Flagged Itl"ti tV (G(ff tile -
NOTE: A survey plat or site plan must accompany this application. Included: W Site Plan ❑Plat(to scale)
(Permit is valid for 60 months with site plan, no expiration with complete plat.)
Owner's Name g:trll AP (1h"06 TAW19 1G{ Phone Number
Owner's Address City/State/Zip
Property Address �� coyilki ctY, City ACiOf)
Lot Size I ,`I l acre. Tax PIN# ansa ,
Subdivision Name(if applicable) Section/Lot# � 22
Directions To Site: P,46N 0 Gill 1 0foit)11 Leri' On UntIP, mis,'Riamon (nua-Clf,
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?
Wes ❑No
Does the site contain jurisdictional wetlands?
❑Yes XNo
Are there any easements or right-of-ways on the site?
❑Yes) No
Is the site subject to approval by another public agency?
❑Yes I(Ni o
Will wastewater other than domestic sewage be generated?
❑Yes I(No
IF RESIDENCE FILL OUT THE BO ELOW v durf"-", I Y /ve"'" o OM
# People -IS— # Bedrooms # Bathrooms t 7. Garden Tub/Whirlpool Utes ❑No
Basement:9Yes ❑No Basement Plumbing: IiYes ❑No
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: )kCCon�rVion l ❑Accepted ❑Innovative ❑Altemative ❑Other
Water Supply Type: )I 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?
Two
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 determine compliance with applicable
lawsVndl'fl
ls. I understan that I am responsible for the proper identification and labeling of property lines and comers and
to agging ting a house/facility location, proposed well location and the location of any other amenities.
rerty own
oper s or er's egal representative signature Site Revisit Charge
Date(s):
Client Notification Date:
Date EHS:
hri�s�u� o,n
boa fy)u)} d
a60)3 )3 i b*r%
ana I by room '
32'
Sign given ❑Yes 0 N Account #
DD�
Revised 11/06 Invoice #
DAVIE COUNTY HEALTH DEPARTMENT o, Q)oIMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION/- F40TE: Issued in Compliance With Article I I of G.'S. Chapter US Wa Nq&4Vt Nv-d-e Permit NumberSanitary Sewage SystemsLocationSec or Block No�
Subdivision
_ _'-
' �
. ��
Lot Size House Mobile Home Business |
l ~r
No, Bedrooms __=�-_-_�No� Baths-���±�__ No in Family Public
Gai,-g---,-- Y-- p NO Soecifications for System:
Au to Dish Washer YES V Nb'[]
Auto Wash Ma-hine
_ No_ -
Type Water S, upply nLz��—
- '
°Thispermit Void /uewaguyo�amoeaoho . |o- xia notinstalled vithin 6 years of issue.
This
.
Th(upermit iosubject ozrevocation ifoi�-»p�noorthe intended use change }`
`^` '``�
.�
- /
-
'
\
\
/ ^ `
Improvements permit by
�
*Contact a representative of the Davie County Health Department for final inspection of this system b wk-- �30- Z
1:00-1:30 P.M. or 4:30-5:00 P.M. on day of completion. Telephone Number: 704-634-5985. 7
't'ii-
Final Installation Diagram: System Installe by
^ ~.
~
'lot'
'
/
�
`
`
`
`
`
Certificate of Completion' Dote
~_
,
'The signing of this certificate shall indicate that the system described above has been installed in compliance with
the standards set forth inthe above regulation,but shall inNOway betaken aoaguarantee that the systenmwill function
satisfactorily for any given period of time. ` ` �^�
6. If business, industry, place of public assembly, other: Specify type
No. of People Served No. of Sinks
No. of Commodes No. of Urinals
No. of Lavatories No. of Water Coolers
No. of Showers Water Usage Figures
7. Type of water supply: B-O'ublic ❑ Private
8. Property Dimensions 22 O X 2/0 :4 2-20 -'/- 33 y Sewage Disposal Contractor
9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes
If vas_ what tvna?
L• •
❑ 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: /s' g L �t-S s o N O N Uv o e R X0/4 S S'
C- . �,,4-5f �.� f o/u �crT
kAl 5
ft�2SF(/r44- `ToQ'�N oN l ���j Lo f I N
-3
This is to certify that the information provided is correct to the best of my kno dge, and I understand a responsible for all charges
incurred from this application.
DATE SIGNATURE
CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY
MUST CHECK ONE: V 1. 1 OWN the property. ❑ 2. 1 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 to determine said site's suitability for a ground absorption sewage treatment
and disposal system.
DATE
DCHD (193)
SIGNATURE
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section
P. O. Box 665
Mocksville, NC 27028
tp
1. Application/Permit Requested By T 6-W UI'L De4s
-:C/v C-1
Mailing Address
o (04S
Home Phone %l o — �! % !� - Sy 6?/
A YA / G E- /V L %DDG
Business Phone 9 9 S- S� Z"
2. Name on Permit if Different
than Above
3. Application for:
❑ General Evaluation "Septic
Tank Installation Permit
4. System to Serve:
louse ❑ Mobile Home
❑ Place of Public Assembly
❑ Business
❑ Industry ❑ Other
❑ Unknown
5. If house, mobile home:
Subdivision Co�,vtL�2v.f�DE
Section Lot #
RBasement/Plumbing
No. of People 2'
❑ Basement/No Plumbing
No. of Bedrooms 3
®fishing Machine
No. of Bathrooms %�
Z
C9'ISishwasher
Dwelling Dimensions
Garbage Disposal
6. If business, industry, place of public assembly, other: Specify type
No. of People Served No. of Sinks
No. of Commodes No. of Urinals
No. of Lavatories No. of Water Coolers
No. of Showers Water Usage Figures
7. Type of water supply: B-O'ublic ❑ Private
8. Property Dimensions 22 O X 2/0 :4 2-20 -'/- 33 y Sewage Disposal Contractor
9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes
If vas_ what tvna?
L• •
❑ 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: /s' g L �t-S s o N O N Uv o e R X0/4 S S'
C- . �,,4-5f �.� f o/u �crT
kAl 5
ft�2SF(/r44- `ToQ'�N oN l ���j Lo f I N
-3
This is to certify that the information provided is correct to the best of my kno dge, and I understand a responsible for all charges
incurred from this application.
DATE SIGNATURE
CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY
MUST CHECK ONE: V 1. 1 OWN the property. ❑ 2. 1 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 to determine said site's suitability for a ground absorption sewage treatment
and disposal system.
DATE
DCHD (193)
SIGNATURE
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
SoiUSite Evaluation
NAME a��a� _��� DATE EVALUATED l 3 ` -9 -1
ADDRESS A'�Q PROPERTY SIZE
PROPOSED FACIILTY ��� LOCATION OF SITE
Water Supply: On -Site Well Community
Public
Evaluation By L��� Auger Boring V Pit Cut
FACTORS
1
2
3
4
Landscape position
_S
.S
_5S �-
Slope 7.
S�
-�
O 'ED
O -
HORIZON I DEPTH
Texture group
Consistence
-
T-
-Z42
Structure
Q1.
Cl�
Mineralogy
HORIZON II DEPTH
Texture group
Consistence�-
Structure
Mineralogy'
I
'
HORIZON III DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
SS
SsS
S -S
RESTRICTIVE HORIZON
—
—
—
-
SAPROLITE
CLASSIFICATION
�S
LONG-TERM ACCEPTANCE RATE -1
3
SITE CLASSIFICATION: \ �� EVALUATED BY: VD�s
LONG-TERM ACCEPTANCE RATE: 3 OTHER(S) PRESENT:
REMARKS:- ����, C.1 �s
DCHD(01-90)
LEGEND
Landscave 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
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMI
Davie County Health Department'
Environmental Health Section [
P. O. Box 665 i
Mocksville, NC 2 28
1. Application/Permit Re ested By. r J
Mailing Address
Home Phone — ��ezv:: Business Phone
2. Name on Permit if Different than Above i
3. Application/Permit for: ❑ General Evaluation Q'Septic Tank Installation
4. System to Serve: Z House ❑ Mobile Home ❑ Place of Public Assembly
❑ Business ❑ Indu try El Other ❑ Unknown
5. If house, mobile home: Subdivision t/�t/T/�11.� Section Lot # 2�
No. of People
No. of Bedrooms
No. of Bathrooms 2 Z
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 Usage Figures
7. Type of water supply: Z Public ❑ Private
8. Property Dimensions 22-0 F x 37b4 x 22-/ZY. 370 ]L Sewage Disposal Contractoi
9. Do you anticipate additions/expansion of the facility this sytem is intended to serve?
If yes, what type?
❑ Basement/Plumbing
B'Basement/No Plumbing
Gk*ashing Machine
"ishwasher
❑ Garbage Disposal
❑ Yes 0No
❑ 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.
This is to
incurred 1
that the information provided is
iis
application.
:S
I understand I am responsible for all charges
CONSENT FOR SITE EVA ATION TO BE DONE ON ABOVE DESCRIBED PROPERTY
MUST CHECK ONE: 1. I OWN the property. ❑ 2. 1 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 t e Davie County H alth Department to enter upon above described
property located in Davie County and owned by
to conduct all testing procedures as necessary to detr e sa' s' ' u' a ili y for a and absorption sewage treatment
and disposal ystem.
DATE SIGNATURE
DCHD (12-90)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
NAME
ADDRESS
PROPOSED FACIILTY
DATE EVALUATED
PROPERTY SIZE
LOCATION OF SITE �✓��%/�
Water Supply:
Evaluation By:
On -Site Well
Auger Boring L/
Community
Pit
Public
Cut
Sloe %
HORIZON I DEPTH
FACTORS 1
2 3 4
Landscape position 1—
<_
Sloe %
HORIZON I DEPTH
Texture group
Consistence
Structure
MineralogX
HORIZON II DEPTH
Texture groupG
G
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: A/
LONG-TERM ACCEPTANCE RATE: -�
REMARKS:
LEGEND
DCHD(01-901
EVALUATED BY:
OTHER(S) PRESENT:
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
■E■AM■
■EMKO■
Address
PAr.TOPA
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
R O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
ARFA 1 ARFA 7
Date le Aor i
Lot Size t?a2"e-rX17rZ
ARFA I APPA A
.9
1) Topography/ Landscape Position
S
IV15
v
S
PS
S
PS
U
U
�) Soil Texture (12-36 in.) Sandy,
Loamy, Clayey, (note 2:1 Clay)
S
Address
PAr.TOPA
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
R O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
ARFA 1 ARFA 7
Date le Aor i
Lot Size t?a2"e-rX17rZ
ARFA I APPA A
.9
1) Topography/ Landscape Position
S
IV15
S
S
PS
S
PS
U
U
�) Soil Texture (12-36 in.) Sandy,
Loamy, Clayey, (note 2:1 Clay)
S
S
S
PS
U
S
PS
U
1) Soil Structure (12-36 in.)
Clayey Soils
S
S
PS
S
PS
U
U
Soil Depth (inches)�
PS
PS
S
PS
S
PS
U
U
U
U
) Soil Drainage: Internal
S
S
qPS
S
S
PS
'V
U
U
External
�
V,
PS
PS
U
U
U
i) Restrictive Horizons
Available Space
PS
U
PS
U
S
PS
U
S
PS
U
1) Other (Specify)
S
PS
S
PS
U/
S
PS
U
S
PS
U
1) Site Classification
/U
U—UNSUITABLE S—SUITABLE PS Provisionally Suitable
Recommendations/Comments: ter. R
Described by fii��9� Title
SITE DIAGRAM
?bb
DCHD (6.82)
3w
Jlyllo
61,
Date
VO-'Z�—)
` DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
MSoil/Site Evaluation Q
NAME �`\\�2 �Q�'t���t� DATE EVALUATED -L ` Ho - c� 1�
ADDRESS S A h. PROPERTY SIZE 1,78
PROPOSED FACIILTY Q LOCATION OF SITE O v RV.S 1 �a
Water Supply: On -Site Well Community Public V
Evaluation By:C. _U Auger Boring Pit Cut
FACTORS
1
2
3
4
Landscape position
,S
S
-'
-3'
Sloe %
O _1R0
078°
HORIZON I DEPTH
6
4,
Texture group
C L
Q L
Consistence
IF 7V
FT
Structure
Mineralogy
HORIZON II DEPTH
y�.."
LA 2
1"
Texture group
C
C
C
Consistence
\
r
Structure
C
Mineralogy
HORIZON III DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
Ss
ss77
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE
SITE CLASSIFICATION: Q'S • EVALUATED BY: \`Sly
LONG-TERM ACCEPTANCE RATE: ` 3 OTHER(S) PRESENT: b
REMARKS: G a., '1�1' - � A,
LEGEND
Landscave 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(01-901
■■■■
■EM■