229 Dublin Road Lot 10APPLICATION FOR SIZE EVALUATION/IMPROYEMENi PERMR &r[IE
i° Davie County Health Department EnvJronmenfal Heath SectionP.O. Box 868/210 Hospital Street8 n
Mocksville, NC 27028
(336)751-8760
***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED
INFORMATION IS PROVIDED. Refer to the INFORiaTION BULLETIN for instructions
3. Name to be Billow - Cr(4 MI'1 O i ` p-/'/� Contact Peron ./
)Ct rtos
- Mailing Address - y <�Y 11
Same
City/state/aIP Business Phone U :- [F 7
2. Name on. Permit/ATC if Different than Above -
Nailing Address -,city/state/zip
3. Application For:41f3lte.Evaluation
e. system to service: XHouse ❑ Mobile Home
S. If Residence: t People
(improvement Permit/ATC ❑ Both
❑ Business ❑ Industry ❑ Other
i Bedrooms
—
IK Dishwasher n Garbage Disposal eftshing Machine
S. If Business/Industry/Other: specify two
6 Commodes 0 shovers
IF FOODSERVICE: g Seats
0 Basement/Plumbing
i Bathrooms - R
D BasementfHo Plumbing
i People # sinks
IF Urinals 0 Nater Coolers
Estimated Nater Usage (sallow per rayl
7. Type of water supply: IVComrty/City
❑ Well.
e. Do you anticipate additions or expansions of the facility tbis system is intended to servet
If yes, what type!
U Yes
***IMPORTANT'** CLIENTS AfUSTCOA[PLETETIIE REQUIRED PROPERTY INFORMATIeN REC?UVl,TFk)
BELOW. Either s PLAT or SITE PLAN MUST BESUBMITTED by the client with THIS APPLICATION.
Property Dimensions: Wd r�N� b 17or � ,goo,Boii1 Si it WRITE DIRE ON from 11 ockrAlle) to PROPERTY:
03 - Jn is Ver; y
Tax Office PIN: # P�7 $ % =.3/
Property Address: Read Name [/��,� .� i�, /� )Z
C'�ru'i�^/ I�[.�.✓3'n"(e-r
City/Zip 4d, latira G, _pn/ �✓ / TLi4<�ro� /wu<or
If in a Subdivision provide information, as follows:
] ��
Name: _ AA 1 /sinc r`eS
Section: �_ Block• Let, 10
tee Pm
perty Flagged:
This is to certify that the information provided is correct to the best of my knowledge. I understand that any permil!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, oko, undera/Gnd that I am relponsole for an chwgesincurred jram
this application. 1, hereby, give consent to the Authorized Representative of the Davie County Heap artment
to enter upon above described property located in Davie County and owned b Al
to conduct all testing procedures as necessary to determine the site suitabilit2. '
DATE ) 0 — Ir- 'gr SIGNATURE
THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN etude all of the following: Existing and proposed
Property lines and dimensions, structures, setbacks, and septic locations).
-101 wi -1-P,�$.vice
n
�p`tifba K
uer .Poo
Revised DC D (07/98)
Account No. ` 9q �/�i3
Invoice No. a1 6
w DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
NAME
ADDRESS 454a., p -k k- % uao
PROPOSED FACIILTY
wl6
DATE EVALUATED
PROPERTY SIZE ?l/��.
LOCATION OF SITE �- e e--4-
Water Supply: On -Site Well Community - Public c/
Evaluation By: Auger Boring Pit v - Cut
FACTORS
1 2 3 1 4
Landscape position
L<
Slope x
HORIZON I DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH
Texture group
C>
Consistence
Structure
J
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 RATE11
SITE CLASSIFICATION:
LONG-TERM ACCEPTANCE RATE: Y
REMARKS:
DCHD (01-901
EVALUATED BY: & //
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- 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
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/ftz