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263-277 Swicegood Street Lots 22A & 22BON NO ,8:6 DAVIE :CgUNT,Y HEALTH DEPARTMENT �� 5 ✓ .: > nviro mental Health Section PROPERTY INFORMATION. �A. .i:r�tr � ,PO.$ox,848 1d ocksviIIe, NC 27028 ;_ , Subdivision Name for r `r� 'ZENVIRQ 'R E HEALTH SPE T '. DA Davie County Health Departmentif r , � • Env/rDnmenfa/HealfhSerHon �� f � D P.O. Box 848/210 Hospital Street Nockaville, HC 27028 NOV 2 5 1998 (336)751-8760 •e*11WORTAHTse+ THIS APPLICATIONK INFORMATION I3 PROVIDED. Refer to the Nv PR TioNr3 UNLESS ALL TRz QUIRED OAVIE COUNTY INPORNATION BULLETIN for ins ons. 1. Barn to be Billed ` e contact parson QC Nailing Address (( 'L some phone City/state/LIP l� ���'I�1 Besiaess Phone% •9 / a. Name on Peffit/ASC if Different than Above_ walling Address 9. Application For: 0 Site Evaluati��on 4. System to Service : 0 House Wflobile Home a. If Residence: 4 People I D Dishwasher a Garbage Disposal =-9Pla S' City/state/Lip. 11 Improvement Permit/ATC6th 0 Business 0 Industry 0 other / Bedrooms .'?_ s Bathrooms _ D Bashing Naahlne 6. If Business/Industry/other: Speaify type 7. I Commodes IF FOODSERVICE - 4 Showers D Basement/Plumbing D Basement/Ho Plumbing 4 People # sinks Urinals i water Coolers ii seats Estimated crater Usage 4 (gallons Per Bay) Tppe of water supply: 9-16ounty/City troll 0 Coaunity s. Do you anticipate additions or expansions of the facility this system Is intended to serve? 11 Yes 0 No If yes, what type? "'/MPORTANT•seCLIENTS AIUSTCtiA/PLEfETHE REQU/RBD PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PIAN AIUST BESUBMIITED by the client with THIS APPLICATION Properly Dimensions: WRITE DIRECTIONS (from Mockrille) to PROPERTY: Tax Office PIN: Property Address: Road Name i St 7.0t ht? iT sjWlc e 0c) City/Zip P—Q Yn Q C S If in a Subdivision provide information, as follows: Name: Section• . Block: Lot• Z Z Date Property Flagged: 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, anderxtaxdthat I am raponsiblefor all charges Incurred from this appUcufiam 1, hereby, give consent to the Authorized Representative of the Dav County Health Deparlmen to enter upon above described property located in Davie County and owned by��2 �, I S to conduct all testing procedures as necessary to determine the site suitsli v n1 ec ac g DATE_ SIGNATURE71f1i?�n a, THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (Imclnddfdl of the folio/Bge Existing and proposed _ Property lines and dimensions, structures, setbacks, and septic locations). i x C] x 171 Account No. ? Revised DCHD (07/98) Invoice Na DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section SECTION LOT Z Z R Soil/Site Evaluation APPLICANT'S NAME PROPOSED FACILITY l ✓l l �" i ' "r' SUBDIVISION Water Supply: Evaluation By: DATE EVALUATED Zf PROPERTY SIZE ROAD NAME IGEC�D On -Site Well Community Public Auger Boring Pit / Cut SITE CLASSIFICATION: v S EVALUATION BY:� to P LONG-TERM ACCEPTANCE RATE: 3 r ri OTHER(S) PRESENT: REMARKS:'.. 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 clay loam SIL - Silty loam . CL - Clay loam- SCL - Sandy clay loam SC - Sandy clay SIC - Silty clay C- Clay Moi , VFR -Very friable FR -Friable FI -Firm VFI'- Very firm E FI - 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 Mineraloev 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 • �1�OREm®�®-- WAVATIM 012122"2 Consistence • • ®-®s®sem ... • ®moo®�®® SITE CLASSIFICATION: v S EVALUATION BY:� to P LONG-TERM ACCEPTANCE RATE: 3 r ri OTHER(S) PRESENT: REMARKS:'.. 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 clay loam SIL - Silty loam . CL - Clay loam- SCL - Sandy clay loam SC - Sandy clay SIC - Silty clay C- Clay Moi , VFR -Very friable FR -Friable FI -Firm VFI'- Very firm E FI - 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 Mineraloev 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 **NOTE** This Authorization to issuance of any E Office .when applyii (In compiiancewith Article 1.1 i IR0NM9N. AL HEALTH Wastewater System Construction: MUST BE ISSUED by the Davie County Environmental Health Section prior ding -Permits. This Fom✓Authorization Number should be presented to the Davie County Building Inspections nor Building Permits. k.S. Chapter 130A Wastewater S)stems, Section .1900 Sewage Treatment and Disposal Systems) , 2' ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION IS VALIDFOR A PERIOD OF FIVE YEARS. T' DATE 1SSU D '.': .. Davie County Health Department &LT Env/ronmenfa/Mea/ChSect/on �P% u� P.O. Box 848/210 Hospital street Moekeville, HC 27028 NOV 2 5 I9M (336)751-8760 +++Z�pRT.ra• ENVIRONMENTAL HEAL THIS APPLICATION CANNOT BE ; INFORMATION IS PROVIDED, Refer to the pMTIOSLD UNLES9 ALL THE-REQUI INFORMATION BULLETIN for instructions. 1. same to be Billed Nailing Address City/state/LIP 2. Name on Permit/ATC If Different than Above Nrlling Address 3• Application For: ❑ site Eval��u ation 6. system to service: ❑ House O'Rob-ile Home s. If Residence: it People 0 Dishwasher D Garbage Disposal Contact person Lqt Business a—snFigme City/state/Lip _�� !✓ice . ❑ Improvement Permit/ATC th ❑ Business ❑ Industry ❑ Other i Bedrooms _ -? f Bathrooms 0 washing machine 6. If Business/Industry/other: Specify type 7. e. 11 COModes # showers IP FOODSERVICE; / Seats 0 Basemmt/Plesbing tl People ! urinals 0 Basement/No Plsnbing __ 1 Sinks i Nater Coolers Estimated Nater `U"saagge (gallons per'day) Type of water supply: 9 runty/City an 11 - e ❑ Communi Do you anticipate additions or expansions of the facility this system is intended to serve? H yes, what type? ty ❑ Yes 0 No At* N7%** CLIENTS AfuncompiETETHE BELOW. Either a PLAT or SITE PLAN AfUST BESUBAffREQUIRED PROPERTY INFORMATION REQUESTED TTED by the client with THIS APPLICATION Properly Dimensions: —� /�' 6,SKi� % ,,p DIRECTIONS(from INocckssville))to(PROPERTY: 'it, Gilice PIN: # -57 T �— `i l9 �l �a�ofN Qkq,// S (O� A l J l?roperty Address: Road Name %ri sin/lc e '0 t. City/Zip 1?QYnp C If in a Subdivision provide information, as follows: 'A 7U� " f' Name: Section:' X` Block: \ Lot: Z .B Date Property Flagged: _�J ;Z >� This It to certify that the information provided h 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 applicaliOD is falsiRed or changed. 1, OLro, anAnWand that lam reVousale for a// charges incurred%rom this appBost am 1, hereby, give consent to the Authorized Representative of the DX* County Health DeparlmeDk to ester upon above described property located to Davie County and owned by _ /) 04 er — .7 r Mgt tt�er� S to conduct all testing procedures as Deetssary to determiDe the site snits11 DATE��/� SIGNATURE ie o!n A A T1XA8 AREA MAY BE USED FOR DRAWING YOUR SITE PLANtsclud v y poi)perty lines and dimensions, structures, ( 1 of the folio IDg: Existing and proposed r'es, setbacks, and septic locations). X Account Na aZ Revised DCHD (07/98) Invoice Na / �7 - = DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section . SECTIONLOT Z.z Soil/Site Evaluation — APPLICANT'S NAME ���i �llk/t^4 r DATE EVALUATED GI b PROPOSED FACILITY PROPERTY SIZE A4C SUBDIVISION ROAD NAME "<-,M11D Water Supply: On -Site Well Evaluation By: Auger Boring Community Public' Pit Cut FACTORS ` 1 2 3 4 5,'' 6- 7 Landscape position t Slope % HORIZON I DEPTH 0o> Texture group - Consistence Structure Mineralogy_ l 1 HORIZON H DEPTH - Texture groupG Consistence Structure 5G V Ic Mineralogy 17 t HORIZON IH DEPTH ' Texture group Consistence Structure . Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION S LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: EVALUATION BY: LONG-TERM ACCEPTANCE RATE: OTHER(S) PRESENT: REMARKS: LEGEND Landscape Position I 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 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 tructure 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 -tern acceptance rate - gal/day/ft2 DC111)(01-90) _