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406-418 Swicegood Street Lots 8A & 8BRESIDEN77gL SPECIPICATIONE BUILDING'TYPE #BEDROOMS-`-j#BATHS" ^Il,.00CUPANTS :' GARBAGE DISPOSAL,Yeso Davie Ceunty Health..... en rurslu a AIG Z�l Envltonmenttl Health Seict/o, P.O. Box 848/210 Hospital Street Noaksville, HC 27028 (336)751-8760 i**nWORTAWX*** THIS APPLICATION CANNOT 8E PROCEgSaD ns XMM9HaTiON IS PROVIDED. Refer to the INFORMATION BOLLETIN for ittsONLE9S:ALL 1. Base to be Billedt7�' Contact Pelson Al Nulling Address City/state/LIP a. Rams on pewit/AiC, i! Different than Above Halling Address 3• Application For: U Site Evaluation 4. a„etea to service: ❑House B'Mobile Home 3..:=SIf;Residence: / People D Dishwasher 0 eaffiage Disposal If 3vsiness/Industry/other: ..A Commodes Baine Phone Business Phone a—svrig e� NOV 25 City/stake/LSP _ 50A . - ❑,Improvement Peanit/ATCX43 6th ❑!Business It Bedrooms "?_ ❑ Industry ❑ Other D Bashing Machine Specify type Showers SF FOODSERVICE: / Seats )'• i of water supply: / Bathrooms _2— D Basement/Plusbing D Basemen!/so Plumbing — i People / Sinks 4 Urinals • water Coolers Estimated Hater `Usage (gallons per day) 0unty/cit. rrAeagll n o. 110 you anticipate additions or elpaus(ons of the facility this system is intended to serve! ❑ yes j ❑ No Niti tuff yes, what type' ""IMPORPAN7•maCLIENTS AlUSTCOAMETETHE REQUIREDPRUPERTYINFORMATIONREQUESTED BELOW. Either a PIAT or SITE PLAN AIUST BESUBAATTED b We Bleat wlth THIS APPLICATION Property Dimensions:. 1—S� WRITE DBIELMONS(flow Moe�lcjsvi Ile) /to�P+ROPERTY: Tas Oltice;SIN:OQ 1 J 76 Property Address: Road Name i' Sf %A kle � � C' / — m .JLt11Lf4V�d City/Zip' 2.QYn60 H in a Subdivision provide information, as follows: (� .. Name: — C) 1,(-M I A )--- ;Section• Block: Lot: Date Property Flagged: This ds to certify that the information provided Is correct to the best of my knowledge. I understand that any permil(s) issued herealler 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, anderstand That I am ►rspossible for all charges Tncarred from fAis application 1, hereby, give consent to the Authorized Representative of the Davjq County Health Departures 10 Cuter upon above described property located in Davie County and owned by _ F pg er — J' �{ to conduit all testing procedures as necessary to determine e site mita � l+proceduresW Sg'� DATE SIGNATURE tiJen TB15 AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (Includdfill of the follo tog: ElIt lug and proposed Property lines and dimensions, structures, setbacks, an septic locations). r� r I F Account No. of� Rev°sed DCHD (07/98) Invoke No. "T Ct�6ti DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section SECTION LOT24 Soil/Site Evaluation APPLICANT'S NAME �� I LES^^ DATE EVALUATED PROPOSED FACILITY r/\• PROPERTY SIZE S• O 20 SUBDIVISION ROAD NAME �Ca600 ST Water Supply: On -Site Well Community Public / Evaluatioti By: Auger Boring' Pit 'Cut— SITE CLASSIFICATION: , t S EVALUATION BY: �� LONG-TERM ACCEPTANCE RATE: C' 6S OTHER(S) PRESENT: // ' Lit 44.4 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 rSI - 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 OR - 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(01-90) - - RMWNILIA. . , o®a-moo® • -®®®®tee SITE CLASSIFICATION: , t S EVALUATION BY: �� LONG-TERM ACCEPTANCE RATE: C' 6S OTHER(S) PRESENT: // ' Lit 44.4 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 rSI - 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 OR - 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(01-90) - - NOME 0 0 ME t0 prolperty: NbiE**jiuS linprovem6nt Permit DOM NO 'AUTHORIZATION FOR' WASTER constrtic6on/irisLinahonofa�iysienio ofj3�8C , t �j fi6pte'r,�l an'comp 1*iance-Wiffi Article 'ENWRONMENTAt- hlEALkH ERC�AL 7777777� TY TYPE j # PEOPLE # PEOPLE/SHIFTLj SEATS - INDUSTRIAL WASTE VYes oi No VDAID 1. Davie County Health Department �mV EnvironmentalileatthSerdon �� D P.O. Box 848/210 Hospital Street Hooksville, HC 27028 (336)751-8760 w** THIS APPLICATION CANNOT IM p1W=SSEo MMUSS ALL THE IS PROVIP IDED. Refer to the 1N1%)PMTION BULLETIN. for ins Hams to bei Billed Hailing Address City/state/SIP 2. Hama on pewit/ATC if Different than Above Hailing Address 3. APPlication For: U Site Evaluation 4• system to service: U House wla-ile Rome S. 'If Residence: 4 People D Dishwasher D Garbage Disposal S. If Busines Contact Person Boma Phone Business Phone City/state/zip — 5�A�- 11 Improvement Permit/ATC th 11 Business l7 Industry 0 other i Bedrooms_ / Bathrooms D washing Machine s/Indestry/other: specify type s COmmodeO # showers IF FOODSERVICE.- A S D Basement/plusbing D Basement/Ho Plumbing 4 People / sinks 4 Urinals 4 Hater Coolers eats Estimated RatUsage - Water �9• (gallons per Har) 7.' Type of water supply: WC'Ounty/City av- 11 e D Community s.' Do you anticipate additions or expansions of the facility this system is intended to serve! D Yes D No H yes, what type! ***IMPORTANT*** CLIENTS AfUST COAIPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. ElthersPLATorSIT PLANAIUSTBESUBMIITEP�-.�__.._ . ... Property Dimensions: Ta:Office PlN: # %� — � —1 � Rr06 Property Address: Road Nate4 j' Sr` City/Zip L _ If in a Subdivision provide information, ss follows: Name: C),7,(h ;A i— DIRECTIONS (from Mocksrille) to PROPERTY: 7OLS � 0U �S !! 1JWlceQ0'J Section: Block: Lot: Date Pro�^ perky Flagged: This is to certify that the information provided is correct to the heat of my knowledge. I understand that an Issued hereafter are subject to suspension or revocation, if the site plans or intended use char Y Peation ) submitted in this application is falsified or ehaoged. 10 also, anderatandthat 1 am raponsiblej r�all charges Incurred from thls appl/catios. 1, hereby, give consent to the Authorized Representative of the DnkCDunty Health Depart to enter upon above described property located in Davie County and owned by j''}}ar 7 to conduct all testing procedures as necessary to determine the site suits li DATE _ -- 9 SIGNATURE _ ��n THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (Includfifdl of the Property lines and dimensions, structures, setbacks, and septic locations). Revised DCHD (07/98) Existing and proposed Account No. v� _ Invoice No. / DAVTE COT TNTY HF.AT'TN T)FPARTMFNT Water Supply: On -Site Well • Community 2 3 4 S ' 6 t 7 Public Evaluation By: Auger Boring Pit - - Cut_ ZT HORIZON I DEPTH . Texture groupC.L Consistence 5$ S S Structure te MineralogyL' HORIZON II DEPTH 71-Z Texture groupL FACTORS 1 2 3 4 S ' 6 t 7 Landscape position - Slope % 7 ZT HORIZON I DEPTH . Texture groupC.L Consistence 5$ S S Structure te MineralogyL' HORIZON II DEPTH 71-Z Texture groupL G Consistence �r r Structure k 5 Mineralogyl , 1 HORIZON III DEPTH Z - 2 rl ^ Texture group CJ:�gg -t Consistence Structure 1� Mineralogy HORIZON IV DEPTH •( Texture group Consistence Structure ... . Mineralogy SOIL WETNESS RESTRICTIVE HORIZON. SAPROLITE CLASSIFICATION ' LONG-TERM ACCEPTANCE RATE! t SITE CLASSIFICATION: • 's EVALUATION BY: LONG-TERM ACCEPTANCE RATE: OTHER(S) PRESENT: REMARKS: LEG .. END 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 - CONSISTENCE ist 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(01-90) _