217 Dublin Road Lot 9e APPUCAT10N FOR SITE EVALUATION/IMPROVEMENT PERMIT & A 0
Davie County Health Department
Environmenta/Hea/HlSeeb 'a CC
P.O. Box 848/210 Hospital Street SEP 2 9 X998
Mockaville, NC 27028
(336) 7S1-8760 ENVIRONMENTAL HEALTH
***IMPn=TANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for / instructions.
1. Barna to be Billed ff t1� 0 C rn ��_ Contact Person � C 1/ 1 � (i � u i
Mailing Address .j 14 or R \ name Phone
City/state/ZIP C
k D �) a.--r7_/� Y Business Phone QL �S
2. Name on Permit/ATC If Different than Above /
Mailing Address City/state/Zip
3. Application For: ❑ Site Evaluation 0—rffip-rovement Permit/ATC ❑ Both
4. system to service: .U_HeuSe ❑ Mobile Home ❑ Business ❑ Industry ❑ Other
S. If Residence:. # People # Bedrooms # Bathrooms'
E-61X10123ber n Garbage Disposal TTB-Vashang Machine D Basement/Plumbing D Basement/No Plumbing
6. If Business/Industry/other: Specify type i People # sinks
# Commodes i Shovers # Urinals
i water Coolers
IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day)
7. Type of water supply: "unty/City ❑ well ❑ Community
e. Do you anticipate additions or expansions of the facility this system Is intended to serve! ❑ Yes 14 No—.
H yes, what type!
**-1MPoRTAN7""sCLIENTS bfUSTCOAfpLETETHE REQUIRED PROPERTY INFORMATION REQUESTED
BELOW. Either a PLAT or SITE PLAN MUST BESUBMITTED by the client with THIS APPLICATION.
Property Dimensions:] (� (� () WRITE DIRECTIONS (from Mocksvllle) to PROPERTY:
Tax Office PIN: t! r]� % - '7 `�j 3Gi �(t'100P S -PD l(S CL
Property Address: Road NameL07L �j1k /
City/Zip-6dyll4U a %rib cm i—, M -
If in a Subdivision provide information, as follows:
Name: CnA-'�'roe(b
Section: Block: Lot: _L
Date Property Flagged: 9- Z q — 9k
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 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 suitab
DATE �—c/r SIGNATURE X
THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (Include all of the following: Existing and proposed
property bines and dimensions, structures, setbacks, and septic locations).
Revised DCHD (07/98)
Account No. —0?1�5
Invoice No. C; I-
DAVIE COUNTY HEALTH DEPARTMENT Gf
Environmental Health Section /
. Soil/Site Evaluation
I:/1u1
ADDRESS - X O rl
PROPOSED FACIILTY
DATE EVALUATED
PROPERTY SIZE /��7G
LOCATION OF SITE t /'B e,
Water Supply: On -Site Well _ Community Public
Evaluation By: Auger Boring - _ Pit Cut
FACTORS
1 2 3 4
Landscape position
7
Slope %
(11
HORIZON I DEPTH
Texture group
Consistence
I
Structure
Mineralogy
HORIZON II DEPTH
�!
Texture rou
C
Consistence
Structure
/ s e,
Mineralogy;.
HORIZON III DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
gel
LONG-TERM ACCEPTANCE RATE
V
SITE CLASSIFICATION:
LONG-TERM ACCEPTANCE RATE:
REMARKS:
DCHD(01-901
EVALUATED BY: l�z1
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
Moist
VFR-Vc-y 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
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(tinsuitable)
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 .
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4'L HEALTH SPECIALIST, 'DATE ISSUED
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