132 West Chinaberry Court Lot 21Account #: 990004057
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Boa 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760
Billed To: Structural Designs LLC
Reference Name: Andy Beauchamp
ATC Number: 4467
Tax PIN/EH #: 5747-21-5820
Subdivision Info: South Arbor Lot # 21
Location/Address: W. Chinaberry Court -27028
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
**NOTE** This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental
Health Section prior to issuance of any building permit(s). This Form/Authorization Number should be presented to
the Davie County Building Inspections Office when applying for building permit(s) (in compliance with Article 11 of
G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems). THIS
AUTHORIZATION FOR WASTEWATER CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS.
Environmental Health Specialist's Signature: 11al/ Date:
CERTIFICATE OF COMPLETION
**NOTE** The issuance of this Certificate of Completion shall indicate the system described on Improvement/Operation Permit
has been installed in compliance with Article 11 of G.S. Chapter 130A, Section .1900 "Sewage Treatment and
Disposal Systems," but shall in NO WAY be taken as a guarantee that the system will function satisfactorily for any
given period of time.
41 = Z Z t\2251
*Z► 2?_AkL. atJ440 �o e
41-3- 1 Z C"
gkta+6►4 Jo
-�L1 fA ar G
hof
"I 40
-O iI 1
^ 2?9
Septic System Installed By: �\ �l. d.0 ((SAA
Lu
u �� C
Environmental Health Specialist's Signatn—IL Date: j"?atr
DCHD 05/99 (Revised)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Box 848/210 Hospital Street /1
Mocksville, NC 27028
(336)751-8760
IMPROVEMENT/OPERATION PERMIT
Account #: 990004057 Tax PIN/EH #: 5747-21-5820
Billed To: Structural Designs LLC Subdivision Info: South Arbor Lot # 21
Reference Name: Andy Beauchamp Location/Address: W. Chinaberry Court -27028
Proposed Facility: Residence Property Size:
**NOTES* Th s ImprovemenUOperation Permit DOES NOT authorize the construction of a septic tank system or any wastewater
system. An AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION must be obtained from this
Department prior to the construction/installation of a system or the issuance of a building permit (in compliance with
Article 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems). THIS
PERMIT IS SUBJECT TO REVOCATION IF SITE PLANS OR THE INTENDED USE CHANGE. YOUR
WASTEWATER SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING SYSTEM.
Residential Specification: Building Type #People #BedroomsyS #Baths R
Dishwasher: )Zf'� Garbage Disposal: ❑ Washing Machine: Basement w/Plumbing: ❑ Basement/No Plumbing: ❑
Commercial Specification: Facility Type 13( #People #People/Shift #Seats Industrial Waste:
Lot Size Type Water Supply G/ 6 Design Wastewater Flow (GPD) �� Site: New Repair El
System Specifications: Tank Size A0 GAL. Pump Tank GAL. Trench Width Stle Rock Depth 1I" Linear Ft.1'00
Other:
As stated to 15A NCAC 18A.1R09(5
Required Site Modifications/Conditions: accepted Systems may alsn i., user)
IMPROVEMENT/OPERATION PERMIT LAYOUT -
FINISHED GRADE. ****NOTICE: Contact a represen
system between 8:30 a.m, to 9:30 a.m. or 1:00 p.m. to 1:30
r
r
D EFFLUENT FILTER RISER(S) IF 6 " BELOW
Davie County Health Department for final inspection of this
day of installation. Telephone # is (336)751-8760.****
Health Specialist's Signature: -IldC/ Date: Q�b���
DCHD 05/99 (Revised)
nq1VATWIJ30R SITE EVALUATION/IMPROVEMENT PERMIT & ATC
Davie County HealtliDepartment
Environmental Health Section
P.O. Boz 848/210 Hospital:Street
MocksvMe; NC 27028'
UN on Eo�,� 36)751-8760/Fax(3 6)751=8786,
ration For: D Site Evaluation/Improvement Permit uthorization To Construct(ATC) D Both
***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
APPLICANT INFORMATION
Name to be Billed WZ Contact Person (I4mi,
Billing Addresso-rG25� Home Phone
City/State/ZIP/lil co� car . /J C 27x 09 Business Phone 2594-
Name on Permit/ATC if
Mailine Address SS
PROPERTY INFORMATION
NOTE: A surveyplat or site
(Permit is valid for 6
Street Address
Subdivision Name
Directions To Site: 490
must accompany this application.
uhs with siteAlan, no expiration with
IF RESIDENCE FILL OUT THE BOX BELOW
# People # Bedrooms # Bathrooms Z Garden Tub/Whirlpool DYes AR ro
Basement: DYes LW6 Basement Plumbing: ❑Yes �o
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/t�ventional DAccepted ❑Innovative ❑Alternative ❑Other
Water Supply Type: County/City Water O New Well ❑Existing Well O Community Well
Do you anticipate additions or expansions of the facility this system is intended to serve? O Yes
If yes, what type?
M
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 understand that I am responsible for all charges incurred
from this application. 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 laws and rules on the above described property located in
Davie C,punjy and owned by
Site Revisit Charge
Property o is or owner's legal resentative signature
Date(s):
!� V Client Notification Date:
Datl EHS:
Sign given DYes DNo Account #
Revised 2/06 Invoice #
Date House/Facility Comers Flagged %Z b6
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?
Ofes DNo
Does the site contain jurisdictional wetlands?
❑Yes kNo
Are there any easements or right-of-ways on the site?
DYes fPNo
Is the site subject to approval by another public agency?
❑Yes E :o
Will wastewater other than domestic sewage be generated?
des ONo
IF RESIDENCE FILL OUT THE BOX BELOW
# People # Bedrooms # Bathrooms Z Garden Tub/Whirlpool DYes AR ro
Basement: DYes LW6 Basement Plumbing: ❑Yes �o
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/t�ventional DAccepted ❑Innovative ❑Alternative ❑Other
Water Supply Type: County/City Water O New Well ❑Existing Well O Community Well
Do you anticipate additions or expansions of the facility this system is intended to serve? O Yes
If yes, what type?
M
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 understand that I am responsible for all charges incurred
from this application. 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 laws and rules on the above described property located in
Davie C,punjy and owned by
Site Revisit Charge
Property o is or owner's legal resentative signature
Date(s):
!� V Client Notification Date:
Datl EHS:
Sign given DYes DNo Account #
Revised 2/06 Invoice #
gI I f tat Duury —a i° - , I \ I I I
w OP S 86 15'00'E 208.71' Total EI 3
1ilo�o� .104735' wEII —10a4. 8'—NIo_ a o^
99.9
I
_
0 4S 89009'15"E 191.32' Total S 86°15'0 EJ I (�`/ jl I �I LS 86° 5'00"E " " S 86°15'00"E I S 88'
�— — 145.58' EIP 1 0• EIP V�J 1�' � no.00'—E1 3 W �P — — I—
X • r t
EIP 4574
.74'"� \ _ /� ,1 b, -p oo,
0
22 I I� V,Y 1� I I I YJ �I ��
IN of ' y�Z
�z j24�
\ 4Z" 23 i 25 26 I
'.J s
7-
94-,00 Obp o
�s �' I o, ps
�yf.�
y,
jM J lI ILP-q� I I® I
_
S 87°14'10kN,. BB. Cy.; So.oO'CH-J T- y
L209.40... GN �' ��N 79°1 1 _ io• x �o se _U .00'-
c6 "E l <� Y5„W N 84 '55,. SE
N 845_45'W 2
`e I S'°''L�i' ber r'.ea ra .-i.. v..{�/lnli
s� mos' It
�Ylc� �.�,_ ,_; so''P�
sc`l 1 �''}}C--F/� C = 84°55'45"E 405.00' Total
!iN I
g20 5%� / / I I ;� w - 133. T r —134.00'—
a: ,
i4 meq/ n. I. I rI �.. r
iz � � / " m.� I I
�I 3I
ED
O�pl
l %k 19 l0 18i 17 �a 16 0
OJ 15
ta_Utllity Easement I 1a' tllity semen
27 .90' — --� '— 129.70' — J ` —�33.50' —{ 1 0'—
�. 3.50'—
",V N '84°55'45"W 1127,48° Total
jr
Parcel 24
.Cart T. carter
0eo.a;$ook 44 0 001
7or,erl; R/A
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Boa 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760
IMPROVEMENT/OPERATION PERMIT
Account #: 990003990 Tax PIN/EH #: 5747-21-5820
Billed To: Swicegood Construction Company Subdivision Info: South Arbor Acres 2 Lot # 21
Reference Name: Kyle Swicegood Location/Address: West Chinaberry Court -27028
Proposed Facility: Residence Property Size:
**NO 1lql*,KlsgmprovemenUOperation Permit DOES NOT authorize the construction of a septic tank system or any wastewater
system. An AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION must be obtained from this
Department prior to the construction/installation of a system or the issuance of a building permit (in compliance with
Article 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems). THIS
PERMIT IS SUBJECT TO REVOCATION IF SITE PLANS OR THE INTENDED USE CHANGE. YOUR
WASTEWATER SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING SYSTEM..
Residential Specification: Building Type _
Dishwasher: ❑ Garbage Disposal: ❑
#People #Bedrooms
Washing Machine: ❑ Basement w/Plumbing: ❑
Commercial Specification: Facility Type #People #People/Shift _
Lot Size Type Water Supply Design Wastewater Flow (GPD)
System Specifications: Tank Size GAL. Pump Tank GAL. Trench Width
Other:
Required Site Modifications/Conditions:
#Seats
#Baths
Basement/No Plumbing: ❑
Industrial Waste: ❑
Site: New ❑ Repair ❑
Rock Depth Linear Ft.
IMPROVEMENT/OPERATION PERMIT LAYOUT - APPROVED EFFLUENT FILTER RISER(S) IF 6 " BELOW
FINISHED GRADE. ****NOTICE: Contact a representative of the Davie County Health Department for final inspection of this
system between 8:30 a.m. to 9:30 a.m. or 1:00 p.m. to 1:30 p.m. on the day of installation. Telephone # is (336)751-8760.****
Environmental Health Specialist's Signature:
DCHD 05/99 (Revised)
Date:
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Boa 848/210 Hospital Street
Mocksvllle, NC 27028
(336)751-8760
Account #:990003990 Tax PIN/EH #: 5747-21-5820
. Billed To: Swicegood Construction Company Subdivision Info: South Arbor Acres 2 Lot # 21
Reference Name: Kyle Swicegood Location/Address: West Chinaberry Court -27028
ATC Number: 4416
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental
Health Section prior to issuance of any building permit(s). This Form/Authorization Number should be presented to
the Davie County Building Inspections Office when applying for building permit(s) (in compliance with Article 11 of
G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems). THIS
AUTHORIZATION FOR WASTEWATER CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS.
Health Specialist's Signature:
CERTIFICATE OF COMPLETION
Date:
* *NOTE* * The issuance of this Certificate of Completion shall indicate the system described on ImprovementlOperation Permit
has been installed in compliance with Article I 1 of G.S. Chapter 130A, Section .1900 "Sewage Treatment and
Disposal Systems," but shall in NO WAY be taken as a guarantee that the system will function satisfactorily for any
given period of time.
Septic System Installed By:
Environmental Health Specialist's Signature:
DCHD 05/99 (Revised)
Date:
FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC
Davie County Health Department
6 2006 Environmental Health Section
Mpi 2 P.O. Box 848/210 Hospital Street
{p1.HFA� Mocksville, NC 27028
WVt :1 vk4 (336)751-8760/ Fax (336)751-8786
kation For: 0 Site Evaluation/improvement Permit Authorization To Construct(ATC) 0 Both
***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
.S til ce c sola'
C,,v5//;uc4 ,.N (
Contact Person /� ( SG i' tr`% �''`"✓
Billing Address
SY I zff4, Jdoa
❑Yes Vlb�
Home Phone "3(r • �5 ✓ -4r/yy
City/State/ZIP ,-Jvc<sw'/
<
:.?7olzu
Business Phone
Name on Permit/ATC if Different than
Mailine Address
11N1' UK1V1A 11U1N
NOTE: A survey plat or site plan must accompany this application.
(Permit is valid for 60 months with site plan, no expiration with
Street Address GJ iso C tL2w c�—B-j� 0 4 • City U
Subdivision Name_
Directions To Site:
Tax PIN# 6A11- Z1 -58w
Size
I_
Date House/Facility Corners Flagged 6--.27-06
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?
❑Yes 99-0—
Does the site contain jurisdictional wetlands?
❑Yes Vlb�
Are there any easements or right-of-ways on the site?
OYes;P
Is the site subject to approval by another public agency?
❑Yes MN'
Will wastewater other than domestic sewage be generated?
❑Yes fro
IF RESIDEN E FILL OUT THE BOX BELOW
# People # Bedrooms �_ . # Bathrooms e j- Garden Tub/Whirlpool es ONO
Basement: ges ONO Basement Plumbing: ❑Yes ONO
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 systemrequeste�onventional ❑Accepted ❑Innovative ❑Alternative ❑Other
Water Supply Type. County/City Water 0 New Well []Existing Well 0 Community Well
Do you anticipate additions or expansions of the facility this system is intended to serve? 0 Yes 0 No
If yes, what type?
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 understand that I am responsible for all charges incurred
from this application. I hereby grant right of entry to the Authorized Representative of the Davie County Health Department to
conduct necessary inspections to determine compjjance wif}t applicable laws and rules on the above described property located in
Davie County and owned by Awe
1 Site Revisit Charge
Property owner's oro eras Jdkal repre ntative signature 2
Date
Sign given ❑Yes ONO
Revised 2/06
Client No alio Date: 1. /
EHS:
Account # 3glo
Invoice #
Is I I I jll
! 1
Plat,Book 6, Pa a -af�2 I 1 3 1
w EIP S 86°15'00"E 208.71' Total EI 3 1 (I
W i •r , 1�1 I I 10 �104.35'� 0104.8'--I o Of
I°.
IN 1 hI 111 1v m 1��/,,�y in I
~o
o I III I I _� oM N E 11 GG�7 ' `�1• ° l
o rn1 1 Q� o 1 ro o o
p (� O N
Z !S 89°09'15"E 191.32' Total S 86°15'0 EJ I V�I I I LS 860 5'00"E ' 99.s
EIP 45.74 145.58'—' -EIP '1 0• EIP 5 EI _ A , S 86°15'00"E it S88
o 0.00' cEI 3 w EIP 100.00_0 1'-' .
RS E i g wg.o� i
/ m 1 I �i Ml Ld 1 0o I
�V Y 2j 22 3 I I o Oio
?epi. ZD� o„`� WI o to �z
N 23
�o� ?
% o'� 24 25 M 2g W �a
o
00•x_, 1 I
��s�oJIQ � IEa-q„
a s Ps �
M� �, L�WO
80. CN L T -I O J I ,—
r 209.40 -.. 6N .,�`q0, s 00' .J
9t' ,.E � N 79�=5„H, N 84"55'45'W o• x o se –U .00'
t 1 ✓5 �t1° g >0�• /) / +r--.�. N 84-5545-W
W 1i5f* f2> SB'o5'E L�i�na-b2/ .r�r_""o ze
I S >•�•/_ �' 60' Pub
Io1 g20' ,�./ W £� I o x•84°55'45"E 405.00' Total
Eh)
- - ,,II'-'-��11-- '33. /T1 r— —134.00_
0' U ent�+i %/ w �'
V ph / 0. 3 1 (n I I
r
O N
N O O
e2 rod
119
�� v r.: v r� $
I / O
17 y 16 � 15
N175,
I
o I
lOMilli yasemnt1I o I 10tit
Y some
—eme27 .90– J4
jo n IL29.70• 33o50' 3. I
Ps
' N 127.48Total
84055'451-W 1' 1 0 –
t_Ta,
Parcel 24
Carl T. Carter
Ossd',B.oOk 44 0 001
Zo„ odi R/A
I ^ /
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS Pte. k�7 L'S U V
Davie County Health Department
EjfG1y� ,� Environmental Health Section FEB 2 8 1996
y� 2 P. O. Box 17
(¢i'IS, Mocksville, NC 27028
N
No. of Commodes
No. of Lavatories ' A
No. of Urinals
No. of Water Coolers
No. of Showers Water Usage Figures
7. Type of water supply: ® Public ❑ Private ❑ Community
8i'.Property Dimensions See attached map Sewage Disposal Contractor
9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes EY -No
If yes, what type?
-NOTE: Improvements Permits shall be valid from date issued. Improvements Permits are subject to
revocation, if site plans or the intended use change. Effective October 1, 1989.
Directions to Property:
PROPERTY INFORMATION REQUIRED:
Tax Office PIN: # _51V-)c�y v
PROPERTY AbDRESS, as follows:
Road Name: South AAbbA
City: MoCkAyitt , N. C.
SUBMIT A PLAT WITH THIS APPLICATION.
Revisions effective October 1, 1995.
This is to certify that the information provided is correct to the best of my knowledge, and I understand I am responsible for all charges
incurred from this application.
FebAuahy 26, 1996 T. - Kyte Sutcegood, agent goA
vd and—EtVae
DATE
CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY
MUST CHECK ONE: ❑ 1. 1 OWN the property. 1J 2. 1 DO NOT OWN the property..
If you checked Box #2, the rest of this form MUST be completed by the owner
��tohhr ppaeeperson authorized by the owner:
1 hereby give consent to the authorized represent ve olo Jue CKoayWoodwalcoartment 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 absor tion sewage treatment
- and disposal system. T. y sego d
Feb,tuahy 26, 1996 y
DATE 61 StGNIATVRE
DCHD'(1193)
1. Application/Permit Requested By T. KNXe Sw.Leegood agent Am MA./Mu. Rod WoodwoAd
30U South Main StAeet
Home Phone 704-634-1010
Mailing Address
MOCKSVILLE, N. C. 27028
Business Phone 704-634-2222
2:. Name on Permit if. Different than Above
3. Application for: iA General Evaluation
❑ Septic Tank Installation Permit
4. System to Serve: .9 House
❑ Mobile Home ❑ Place of Public Assembly
❑ Business ❑ Industry
❑ Other ❑ Unknown o21
_2
5. If house, mobile home: Subdivision SottfQRSOR
Section Lot #
❑ Basement/Plumbing
No. of People 3/4
❑ Basement/No Plumbing
No. of Bedrooms 3
® Washing Machine
No. of Bathrooms 2
Q Dishwasher
Dwelling Dimensions 13UU sq. deet +-
❑ Garbage Disposal
6. If business, industry, place of public assembly, other: Specify type
No. of People Served
No. of Sinks
N
No. of Commodes
No. of Lavatories ' A
No. of Urinals
No. of Water Coolers
No. of Showers Water Usage Figures
7. Type of water supply: ® Public ❑ Private ❑ Community
8i'.Property Dimensions See attached map Sewage Disposal Contractor
9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes EY -No
If yes, what type?
-NOTE: Improvements Permits shall be valid from date issued. Improvements Permits are subject to
revocation, if site plans or the intended use change. Effective October 1, 1989.
Directions to Property:
PROPERTY INFORMATION REQUIRED:
Tax Office PIN: # _51V-)c�y v
PROPERTY AbDRESS, as follows:
Road Name: South AAbbA
City: MoCkAyitt , N. C.
SUBMIT A PLAT WITH THIS APPLICATION.
Revisions effective October 1, 1995.
This is to certify that the information provided is correct to the best of my knowledge, and I understand I am responsible for all charges
incurred from this application.
FebAuahy 26, 1996 T. - Kyte Sutcegood, agent goA
vd and—EtVae
DATE
CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY
MUST CHECK ONE: ❑ 1. 1 OWN the property. 1J 2. 1 DO NOT OWN the property..
If you checked Box #2, the rest of this form MUST be completed by the owner
��tohhr ppaeeperson authorized by the owner:
1 hereby give consent to the authorized represent ve olo Jue CKoayWoodwalcoartment 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 absor tion sewage treatment
- and disposal system. T. y sego d
Feb,tuahy 26, 1996 y
DATE 61 StGNIATVRE
DCHD'(1193)
DAVIE COUNTY HEALTH DEPARTMENTC) -
Environmental Health Section
Soil/Site Evaluation O
NAME 1 DATE EVALUATED 3 - � / �o
ADDRESS PROPERTY SIZE D- 3x
PROPOSED FACIELTY cz-"LOCATION OF SITE
Water Supply: On -Site Well Community Publicy
Evaluation By4Z 'T.L.Auger Boring Pith t.� Cut
FACTORS
1
2 3 1 4
Landscape position
S
Slope Z
0ks
HORIZON I DEPTH
tt
'
Texture group
1Z L
Consistence
YZ
S
Structure
CV1-
Mineralogy1
11
HORIZON II DEPTH
L4211
11
Texture group
Consistence
3
Structure
VIB
Mineralogy
HORIZON III DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
—
SAPROLITE
—
—
CLASSIFICATION I
X.S,
I WIN
LONG-TERM ACCEPTANCE RATE
tV
I 0-1
SITE CLASSIFICATION: ' i •S, 1� EVALUATED BY: a
LONG-TERM ACCEPT NCE RATE: ` OTHER(S) PRESENT:
REMARKS:e� �` Al
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(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/fl2
DCHD (01-901