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133 North High Field Road Lot 38• 1 ■ ■■...r-�■� ■ ■ ■ vim■ �■� ■ ■�■�■� ■ ��V■..■.�i"w ••na Davie County Health Department 1�( 210 Hospital Street `1� P.O. Box 848 It C 1 Mocksville NC 27028 Phone: 336-753-6780 Fax: 336-753-1680 Applicant: Jimmy T Johnson Address: 133 N High Field Rd City: Advance State/Zip: NC Phone #: (336) 448-7050 27006 *CDP File Number 156825 m1 County ID Number: Evaluated For: HDRNVWC /,,property Owner: Jimmy T Johnson Address: 133 N High Field Rd City: Advance State/Zip: NC 27006 hone #: (336) 448-7050 Property Location 8r Site Information Address 133 N High Field Rd Subdivision: Windemere Road # Advance NC 27006 Phase: Lot: 38 SINGLE FAMILY Township: *Structure: Directions # of Bedrooms: 4 # of People: Beauchamp Rd South, Right on Windemere D. Right on High Meadows Right on N Highfield Rd. *Water Supply: PUBLIC Basement: ❑ Yes ❑ No Type of Business: Total sq. Footage: No. Of Employees: "Proposed Improvement: Storage building Maintain 5 foot setback from septic system as was staked at time of site visit This release in no way expresses or implies that the existing subsurface sewage treatment and disposal system serving the site will continue to function for any period of time. Applicant/Legal Reps. Signature Required? Oyes ONO Applicant/Legal Reps. Signature: *Date: / / *Issued By: 2140 - Nations, Robert *Date of Issue: 0 7 / a 9 / .l 0 1 4 Authorized State Agent: t—� **Site Plan/Drawing attached.** Hand Drawing 0 Import Drawing Characters Remaining 672 Drawing Type: Davie County Health Department 210 Hospital Street P.O. Box 848 Mocksville NC 27028 Health Department Release Page 2 of CDP File Number: iuvocz) - County File Number: Date: 07 / a9/ 2014 O Inch Scale: O Block O N/A Phone: (336) - 753 - 6780 Davie County Health Department Environmental Health Sectionf' P.O. Box 848 kt 210 Hospital Street I s RECEIVED Courier #: 09-40-06 FAMD_ ; 3 Mocksville, NC 27028a� Dm* - d� !' `� Daw-47 Fax: (336) - 753-1680 ON-SITE WASTEWATER CERTIFICATION (Check One) Replacement Remodeling Reconnection Name: 3M*YKV Phone Number &&� ! Er'%0 (Home) Mailing Address: n X33�• ,�/� {rrrN r-1 Eo (Work) (Work) owce i A4 ?- Qw6 Email Address: Ja% h:50A 703 e VAJwI.CCrn Detailed Directions To Site: Property Address: S4y�to Please Fill In The Following ��Information About The EXISTING Facility: C Name System Installed Under: , f -f-a tin �Lk/A+ Type Of Facility: l Date System Installed (Month/Date/Year): 2 o I -'j Number Of Bedrooms: 14 Number Of People: a. Is The Facility Currently Vacant? Yes 9 If Yes, For How Long?, Any Known Problems? Yes P If Yes, Explain: Please Fill In The Following Information About The NEW Facility: Type Of Facility: 5'`(d ra , -P V I f� l % 1 Number Of Bedrooms: Number of People_ Size: Other: For Environmental Health Office Use Only Approved Disapproved Comments: Environmental Health Specialist Date: *The signing of this form by the Environmental Health Staff is in no way intended, nor should be taken as a guarantee (extended or limited) that the on-site wastewater system will function properly for any given period of time. Payment: Cash Paid By: Money Order # --53 3 0 Amount:$ LIZA Account #: Invoice #: Date: l -A0 — 0 Account #: 990005029 Billed To: Dream Built Inc. Reference Name: Proposed Facility: Residence ATC Number: 5918 DAVIE COUNTY ENVIRONMENTAL HEALTH P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)753-6780 / Fax # (336)753-1680 OPERATION PERMIT Tax.PINI H #: F8020B0038 Subdivision Into: Windemere Fams Lot # 38 LocationiAddress: 133 N. High Field Road -27028 Property, Size: 0.850 Ac **NOTE** The issuance of this Operation Permit shall indicate the system described on the ATC 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. Lbw Cay System Type: S.T. Manufacturer CO- Tank Date q -a3 Tank Size 100 Pump Tank Size / Bedrooms: I-/ System Installed By: G, t it l C 101y [0 Vy - Installer# Date: �3 GPS Coordinate: DCHD 11/06 (Revised) DAVIE COUNTY ENVIRONMENTAL HEALTH `N x P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)753-6780 / Fax # (336)753-1680 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION Account #: 990005029 Tax P1NIEH #: F8020B0038 Billed To: Dream Built Inc. Subdivision info. Windemere Fams Lot # 38 Reference Name: LocationiAddress: 133 N. High Field Road -27028 Proposed Facility: Residence Property Size: 0.850 Ac ATC Number: 5918 Site Type: ❑New ❑Repair ❑Expansion **NOTE** This Authorization to Construct (ATC) MUST BE ISSUED by the Davie County Environmental Health Section prior to issuance of any building permit(s), (in compliance with Article 11 of G.S. Chapter 130A Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems). THIS AUTHORIZATION TO CONSTRUCT IS VALID FOR A PERIOD OF FIVE YEARS. This ATC is subject to revocation if site plans, plat .or the intended use change. Residential Specifications: # Bedrooms # Bathrooms -A6 # People 2 Basement❑ Basement plumbing❑ Non -Residential Specifications: Facility Type # People # Seats Square Footage(or Dimensions of Facility) Lot Size Type of Water Supply: I(County/City ❑ Well ❑Community Well System Specifications: Design Wastewater Flow (GPD) q v Tank Size= GAL. Pump Tank _/' GAL. l i W Trench Width �?,,Max. Trench Depth Rock Depth Linear Ft. Site Modifications/Conditions/Oil%6tatt;d in 15A NCAC 18AASGG_(6 ace Contact the Davie County Environmental Health Secti s ection of this system between 8:30 — 9:30a.m. on the d installation. Telephone # 336 751-8760. ow 4- Environmental Health Special: T-WPT) 11 inA (PPuicPrl) � 2DiZ 04 %g ProFas 78' 7� line 73 Z39 v 106 ol Loo- 3 g wi n %Imm j s APPLICATION FOR SITE EVALUATIONMOROVEMENT PERMIT & ATC Davie County Environmental Health P.O. Boz 848/210 Hospital Street Mocksville NC ' 27028 (336)753-6780/ Fax (336)753-1680 Application For: o Site Evaluation/Improvement Permit o Authorization To Construct (ATC) o Both Type of Application: oNew System oRepair to Existing System oExpansion/Modification of Existing System or Facility ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. APPLICANT INFORMATION Name _ Address Email 104r,A Name onq5ermitTATC Mailing Address Different than PROPERTY INFORMATION Contact Person IC I h UAIMPn J Home Phone 3S t,, 14 O, :uL4 Business Phone 33&, bl , c(O?_(� *Date House/Facility Corners NOTE: A survey plat or site plan must accompany this application. Included: o Site Plan oPlat(to scale) (Permit is v lid for 60 mont s with site plan, no expiration with complete plat.) Owner's Name p<Vi O- Phone Number Owner's Address ZO51 i?S City/State/Zip W,$, Ne, Z%%L)(2 Property Address { Fie I d City Lot Size 0, A C • Tax PIN# F q 0 W B017 Subdivision Name(if applicable) Section/Lot#-139 Directions To Site: If the answer to any of the following questions is "Yes",supporting docu entation must be attached: Are there any existing wastewater systems on the site? _Yes VNo Does the site contain jurisdictional wetlands? Yew YNo Are there any easements or right-of-ways on the site? _vYes No Is the site subject to approval by another public agency? _Yes Will wastewater other than domestic sewage be generated? Yes YNoo IF RF,SIDENCE FILL OUT THE BOX BELOW 12 # People 2 # Bedrooms 4— # Bathrooms 3. 5 Garden Tub/WhirlpoolgYes oNo Basement: oYes No Basement Plumbing: oYes 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: Xconventional oAccepted olnnovative oAlternative oOther Water Supply Type*ounty/City Water o New Well oExisting Well o Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? o Yes 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, 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 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. I understand that I am responsible for the proper identification and labeling of property lines and comers and loca' and fl gin or king the house/faci ity location, proposed well location and the location of any other amenities. Property owne s or ow er's legal representative signature Site Revisit Charge Date Sign given oYes oNo Revised 11/06 Date(s): Client Notification Date: EHS: -A WO Account # Invoice # DAVIE COUNTY ENVIRONMENTAL HEALTH P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)753-6780 / Fax # (336)753-1680 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION .Account #: 989900136 Tax PINIEH #: 5870-49-8834 Billed To: Westview Development Co. Subdivision Info: Windemere Fams Lot #38 Reference Name: LocationiAddress: 129 North High Field Road -27006 Proposed Facility: Residence Property Size: .902 Ac ATC Number: 5811 Site Type: ❑New ❑Repair ❑Expansion **NOTE** This Authorization to Construct (ATC) MUST BE ISSUED by the Davie County Environmental Health Section prior to issuance of any building permit(s), (in compliance with Article 11 of G.S. Chapter 130A Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems). THIS AUTHORIZATION TO CONSTRUCT IS VALID FOR A PERIOD OF FIVE YEARS. This ATC is subject to revocation if site plans, plat or the intended use change. Residential Specifications: # Bedrooms # Bathrooms # People Basement❑ Basement plumbing❑ Non -Residential Specifications: Facility Type # People # Seats Square Footage(or Dimensions of Facility) Lot Size Type of Water Supply: ❑County/City ❑Well ❑Community Well System Specifications: Design Wastewater Flow (GPD) Tank Size GAL. Pump Tank GAL. Trench Width Max. Trench Depth Rock Depth Linear Ft. Site Modifications/Conditions/Other: Contact the Davie County Environmental Health Section for final inspection of this system between 8:30 — 9:30a.m. on the day of installation. Telephone # (336)751-8760. Environmental Health Specialist DCHD 11/06 (Revised) DAVIE COUNTY ENVIRONMENTAL HEALTH s P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)753-6780 / Fax # (336)753-1680 OPERATION PERMIT Accnunt #: 989900136 Tax.PIN!EH #: 5870-49-8834 Billed To: Westview Development Co. Subdivision Into:, .Windomete Fams Lot # 38 Reference Name: -:: LocationiAddress: 129 North High Field Road -27006 Proposed Facility: Residence Property Size: .902 Ac ATC Number: 5811 **NOTE** The issuance of this Operation Permit shall indicate the system described on the ATC 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. System Type: S.T. Manufacturer Tank Date Tank Size Pump Tank Size System Installed By: E.H. Specialist: Date: GPS Coordinate: DCHD 11/06 (Revised) Davie County Environmental Health P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)753-6780 / Fax (336)753-1680 IMPROVEMENT PERMIT Account #: 989900136 Tax PIN/EH #: 5870-49-8834 Billed To: Westview Development Co. Subdivision Info: Windemere Fams Lot # 38 Address: 2631 Reynolda Road Location/Address: 129 North High Field Road -27006 City: Winston Salem Property Size: .902 Ac Reference Name: Proposed Facility: Residence **NOTE**This Improvement Permit DOES NOT authorize the construction of a wastewater system. An Authorization To Construct a wastewater system must be obtained from this office prior to the construction/installation of a wastewater system or the issuance of a building permit(in compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems). This Improvement Permit is subject to revocation if site plans, plat or the intended use change. Permit Type: RNew ❑Repair ❑Expansion Permit Valid for: X Years ❑No Expiration Residential Specifications: # Bedrooms # Bathrooms , # People Basement❑ Basement plumbing[] Non -Residential Specifications: Facility Type # People # Seats Square Footage(or Dimensions of Facility) Design Flow(GPD):` / 0 Site Modifications/Permit Conditions: Type of Water Supply: Arounty/City ❑Well ❑Community Well System Type LTAR Initial P c Repair S°o P Environmental Health Lp.11-06 4 APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC Davie County Environmental Health P.O. Box 848/210 Hospital Street RECEIVED Mocksville, NC 27028 (336)753-6780/ Fax (336) 753-1680 AUG 0 5 2011 Application For: N Site Evaluation/Improvement Permit ❑ Authorization To Construct(,ULtYIE C(ltAR} y rttNmu hi.)Ll NMilA*N1 Type of Application: ❑New System ❑Repair to Existing System ❑Expansion/Modification of Existing System or Facility ***IMPORTANT*** THIS APPLICATION CANNOTBE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. n n APPLICANT INFORMATION JV_ M& t &C1d/1PSS * D11 / s �R�,/Y (QJ Q,D � • C(�Y1� Name to be Billed Westview Development Company Contact Person Brant H. God Billing Address 2631 Reynolda Road Home Phone 336-399-0398 City/State/ZIP Winston-Salem, NC 27106 Business Phone 336-777-0078 Name on Permit/ATC if Different than Above Mailing Address - mobile FKUFhKI Y 1NfUKMA11UN 'Late House/racility Comers rlaggeo NOTE: A survey plat or site plan must accompany this application. Included: N Site Plan 11Plat(to scale) (Permit is valid for 60 months with site plan, no expiration with complete plat.) Owner's Name Westview Development Company —PhoneNumber 336-777-0078 Owner's Address 2631 Reynolda Road City/State/Zip Winston-Salem, NC 27106 Property Address 129 North High Field Road City Advance Lot Size .902 ac Tax PIN# 5870498834 Subdivision Name(if applicable) windemere Section/Lot# 3 8 Directions To Site: south on beaucha= rt on windemere dr. rt on high meadows rt on N highfield rd lot at end on left. 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 14No Does the site contain jurisdictional wetlands? ❑Yes 7,No Are there any easements or right-of-ways on the site? ❑Yes KNo Is the site subject to approval by another public agency? ❑Yes NNo Will wastewater other than domestic sewage be generated? CYes NNo IF RESIDENCE FILL OUT THE BOX BELOW # People ? # Bedrooms 4 # Bathrooms ? Garden Tub/Whirlpool ❑ Yes XNo Basement: 1JYes XNo Basement Plumbing: ❑Yes ❑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: ?;Conventional 7 -Accepted Nlnnovative ❑Alternative ❑Other Water Supply Type: XCounty/City Water ❑ New Well ❑Existing Well i I Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? I I Yes If yes, what type? x No 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 laws and rules. I understand that I am responsible for the proper identification and labeling of property lines and corners and locating and flagging or staking the house/facility location, proposed well location and the location of any other amenities. Site Revisit Charge Property owner's or 0 n r' legal representative signature Date(s): q-1/ n nM 1 ,.fin _10 Client Notification Date: Date '�•/ � z'tt 'l=Ci� EkIS: Sign given UYes l7No Revised 11/06 10—S— (l P&C :R r rN6 101(olt�� Account # q 19 c 6 3 �, Invoice # C a %Now:: "� ter7 - It-, vrwl� mo '� E® ENV 2011 0 �� ��l1 RSSOCIRTER PR 5401 Thacker Dairy Road / Greensboro, NC / 27406 / 336-215-8820 / jbeeson6@gamil.com Job # 2011-88 Project Manager X Beeson Date July 21, 2011 Client WEslview Development County Davie Road North High Field Suitable for preliminary planning purposes on approval by the county health department on a Ic should be used as a general guide, some adjust in the field due to soil variability and topographic only reflects existing soil suitability for on-site sr not valid without accompanying Legend ® usable soils � proposed lines 40 20 0 40 80 120 Feet 40 I edm ENYIIONM ENT11 ASSOCIATES, PA 5401 Thacker Dairy Road / Greensboro, NC / 27406 / 336-215-8820 / jbeeson6@gamil.com N W+ E S FID 0 1 2 7 6 6 7 8 9 10 11 Job # 2011-88 Project Manager JL Beeson Date July 21, 2011 Client WEstview Development County Davie Road North High Field Suitable for preliminary planning purposes on approval by the county health department on a Ic should be used as a general guide, some adjust in the field due to soil variability and topographic only reflects existing soil suitability for on-site sr not valid without accompanying 40 20 0 Legend usable soils «ttt� proposed lines 40 80 120 Feet i APPLICANT INFORMATION A- -+ 4f- aaa nniiR DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section soil/ Site Evaluation Tax PIN/EH #: 5870-�P�tA RTY INFORMATION Billed To: We - tview Development Co. Subdivision Info: Windemere Fams Lot # 38 Reference Name: Location/Address: 129 North High Field Road -27006 'roposed Facility: Re idence Property Size: .902 Ac Date Evaluated: Water Supply: On -Site Well Community Public Evaluation By: Auger Boring__ Pit Cut FACTORS 1 2 3 4 5 6 7 Landscape position Slope % �%e441le HORIZON I DEPTH Texture group L C Consistence i ,, +.. .^ Structure S77 'r Mineralogyl HORIZON II DEPTH Texture group 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 ACCEPT CE RATE SITE CLASSIFICATION EVALUATION BY: LONG-TERM ACCEPTY NCE RATE: OTHER(S) PRESENT: REMARKS: Landscape Position LEGEND R - Ridge S - Should r L - Linear slope FS - Foot slope N - Nose slope CC - Concave slope V - Convex slope T - TerraceFP - Flood plain H - Head slope Texture S - Sand LS - Loam 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 moost VFR - Very friable - Friable FI - Firm VFI - Very firm EFI - Extremely firm 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 - Thic ness and inches from land surface Saprolite - S(suitable), U( nsuitable) Soil wetness - Inches fro 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) TTAR - T.nno_tarm arrvnt nrP rntP - anllrlaulft) T%f'TTT% ACJnC in__.:__� ■■■M■■■■ ■ ■ ■ ■ ■■ ■ ■■■■■■■■ ■■■■■■■■ ■■■■■■■■ ■■■■■■■■ ■■■■■■■■ ■■■■■■R■ ■■■■■■■■■■ ■■■■■■■■■■ ■■■■■■■■■■ ■■■■■■■■■■ ■■■■■■■■■■ V APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC Davie County Health Department Enviivnmenhd Health Sectfan P.O. Box 848/210 Hospital Street Mockeville, NC 27028 (336)751-8760 AUG 2 5 1999 ***nWCRTAPT*** THIS APPLICATION CANNOT BS PRO SSZD UMLa88 ALL Tisa REQUIRaD iMr MWXON IS PROVIDaD. Refer to the INrORMIITIOH HULLaTIN for instructions. 1. Masa to be silled WESi'V1Eu± DCVO INPa COMPJWY Contact person —$W) GtVAEY Mailing Address 2L3% 944), o1-nA RO. Nose phone 3300-1.008 city/state/s:a ,tic Business phone 336•111- odic Z. Masa on pewit/ATC it Different than Above Mailing Address City/state/sip s. Application ror: 198its svaluatioa O Improvement Permit/ASC O Both fW0*100 4. systes to services D�HouseS 13 Mobile Home O Business 13 Industry 13 Other s. If Residence: + people s Bedrooms b Bathrooms O Dishwasher 0 Garbage Disposal 0 lashing Machine 0 sasesent/plushing 0 saseseat/Mo plumbing 6. !f sasinsss/Industry/Other: "City type t people i sinks # cossodes # showers # Urinals b later coolers It FOODSaR71CZ: # Seats aatimated Nater Usage tgallons per day) 7. Type of water supply: 13 county/City O Well a communi-�tty a. Do you anticipate additions or expansions of the facility this system Is intended to serve? ❑ Yes 13No If yes, what type? ***IMPORTANT*** CLIENTS MUSTCOMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED BEIAW. Either a PLAT or SITE PLAN MUST BESUBMITTED by the client with THIS APPWCATION. Property Dimensions: S- Tax Office PIN: # �lS �U 6.y /VC31, �9 Property Address: Road Name /J�%'� 4(C L&I'h"eL61, City/Zip /%�r/d�1cc -lac-"2%EVC WRITE DIRECTIONS (from Mocksville) to PROPERTY: Mocks Cuwu1 To Qodt cum RIgVUUMPAd PKP1VkTV a.rJ If In a Subdivision provide Information, as follows: Name: � � 10*82V 7:e%c-ll Sections ?/ Blocks Lot: Date Property Flagged: F-,25 A This Is to certify that the information provided is correct to the but of my knowledge. I understand that any permit(s) Issued hereafter are subject to suspension or revocation, if the site plans or intended an change, or if the information submitted in this application Is falsified or changed. 1, also, understand that I ant responsible for all charges incurredf om this appUcadou. 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 suitability. I 160�11 01 115; THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (Include all of the Wowing: Existing and proposed property lines and dimensions, structures, setbacks, and septic locations). Revised DCHD (07/99) Site Revisit Charge Date(s): I Client Notification Dates I ERS: Account Na X?c Invoice No. 106 K ON PUCE4 63 37 T FENCE CO6NER LAWRENCE L. MOCK BY WILL REF:D.B. 49 Pg. 8 '44 DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION Account #: 989900136 Billed To: Westview Development Co. Reference Name: Brant Godfrey Proposed Facility: Residence Property Size Water Supply: Evaluation By: On -Site Well Auger Boring PROPERTY INFORMATION Tax PIN/EH #: 5870-69-0403.38 Subdivision Info: Windemere Farms Sec.2 Lot # 38 Location/Address: Beauchamp Road -27006 See Map Date Evaluated: l 0 l 1 9 Community Pit Public Cut FACTORS 1 2 3 4 5 6 7 Landscape position L_ Sloe % 26 HORIZON I DEPTH 0.% O Texture group Gt- Consistence fr 55 SP Structure Mineralogy HORIZON II DEPTH •— 1 Texture group'C Consistence Structure t3 Mineralogy HORIZON III DEPTH Texture group C Consistence r Structure 1L Mineralogy; HORIZON IV DEPTH -} Texture groupD Consistence �S 5 Structure C Mineralogy1 SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION U LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: 1 S EVALUATION BY: Jt -f' `I9tVG41441 LONG-TERM ACCEPTANCE RATE: 0.5 OTHER(S) PRESENT: REMARKS: Q OC_V__ ir�) P i l 'F2- t'az,-- LEGEND Landscaae 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 05/99 (Revised)