476-484 Swicegood Street Lots 11A & 11BX19 �J DAVIE OUNTY HEALTH DEPARTMENT
iMPRO�EMENT AND OPERATION PERMITS PROPERTY INFORMATION
r f
to
property- (�<L / ! /'; . Of
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Davie County Health Department rounrr a All;
Envimnmenfa/Health Section
P.O. Box 848/210 Hospital Street
Mockaville, HC 27028
(336)751-8760
***Il1PORTAI\'T•** THIS APPLICATIOH CANNOT BE PROCEgSyD Olr=SS ALL THE AES
INFORMATION IS PROVIDED. Refer to the IHFORMt1TIOH BM=TIH for ins
truc
1. Name to be BSlled ` t
contact vers
os Q
Nailing address
city/State/LIP leo.1,0 0 frig ,1 p
t. Sam on Peadt/ATC If Different than Above
Nailing Address
3. Application Por: U Site Evaluation
6. system to Service: D House O'Mobile Home
S. If Residence: / People
0 Dishwasher 0 garbage Disposal
6. if Busi
7.
e.
I
Bome Phone
Business Phone
��svrrr!c
te NOV 2 5 1998
city/sta/alp _. 1A i
D Improvement Permit/ATC Ih
0 Business U Industry 0 Other
# Bedrooms t # Bathrooms _ 2
0 as
Washing Machine .0 Besent/plumbing
n
ass/Industry/other: specify type
0 Basement/No Plumbing
f People / Sims
# Commodes f Showers
# Urinals t+ Water Coolers
11 FOODSERVICE: # Seats Estimated gator Usage 4 (gallons Per day)
Type of;water supply: runty/City Nil
e D Community
Do you anticipate additions or expamious of the facility this system Is intended to serve! 0 Yes
If yes, what type''
"••IMPORTANT••• CLIENTS AIUST COAIPLETETHE REQUIRED PROPERTY INFORMATION REQUESTER
BELOW. Either a PLAT or SITE PLAN AIUSTBESURArl Tv^�
\ Property Dimensions:
Tax Office PIN:.,
Properly Address: Road Name St
City/Zip t?fd 7n p C� .' _
If In a Subdivision provide information, as follows: 7Ul _
Name: 0M"YlI"I f
Section: Block: Lot: f // f
Date Property Flagged:—J/ -- ;Z rj •--9
U No
DIRECTIONS (from Moccklvi�lle)/to�PROPERTY:
70 S /8j 0U
I
O
ed
This is to certify That the leformation'previded Is correct to the heat 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, also, understand that l am responsible for all charges tscarred from
this dOPlicat om 1, hereby, give. consent to the Authorized Representative of the DSVk County Health Department,
to ester upon above described property located in Davie County and owned by f p q Qy — J"'
to conduct all leafing procedure as necessary to determine We site snits li r _ g t hae� S�,
DATE /
Jf SIGNATURE flls4f,In
THIS AREA MAY BE USED FOR DRAWING YOUR SITE PIAN (Includdill or the folloing: Existing and proposed
property line and dimensions, structures, setbacks, and septic locations).
/ .. 1166- Account No.
Revised DCHD (07/98) ,z!���
Invoice No.
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section ..SECTIOri LOT.JJA
Soil/Site Evaluation
Water Supply:
Evaluation By:
On -Site Well
Auger Boring "
DATE EVALUATED IIS �p
PROPERTY SIZE S• O Zo t�
ROAD NAME
Community Public
Pit Cut
SITE CLASSIFICATION: EVALUATION BY:IlA
7r J
LONG-TERM ACCEPTANCE RATE: D 7� 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
SL- 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
Moi i
VFR - Very friable FR - Friable FI -Firm .. ry rm ' , 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
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
DCHD(01-90)
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Consistence
SITE CLASSIFICATION: EVALUATION BY:IlA
7r J
LONG-TERM ACCEPTANCE RATE: D 7� 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
SL- 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
Moi i
VFR - Very friable FR - Friable FI -Firm .. ry rm ' , 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
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
DCHD(01-90)
0
No
ME
0
MEN
System Construction MUSTBE ISSUED by the Davie Couny Environmental Health Sectimi prior
This Form/Authorization Number should be presented to the Davie CountyBuilding Inspections._;,
Davie County Health Department
jr Environmenta/Health5L-CUOn 6`7 Q L� a
y, P.O. Box 848/210 Hospital Street DI
Mockaville, HC 27028 NOV 2 5 1998
(336)751-8760
***1?PORTANT*** THIS APPLICATION CANNOT BE pROMSSBD MURSS ALL THE RE I •• EALTH
INFORMATION IS PROVIDED. Re£er to theDAVIECDUN
IHFORMATIOH BULLETIN for instru ons.
1. Nam to be Billed
Contact PersonE7
Nailing address
!�
City/state/zip some Phone C. a�01-I
Business Phone
Z. Name on Pereit/ATC if Different than Above _^ //A•%,��II (` (�
Mailing— J°'� �-�^l1/ih I'LL 7�rIJ h
Address �il-i,�..
, City/elate/rip _ 5�iAhi
3. Application For, U Site Evaluation ❑ Improvement Peewit/ATC
� �� th
e. System to Service: ❑ House 9'Robile Home ❑ Business ❑ Industry ❑Other
e. If Residence: / People
4 Bedrooms i Bathrooms 2_
D Dishwasher U Garbage Disposal D Washing Machine D Basement/Plwabinq D Basement/No Plumbing
6. If Business/Industry/Other: Specify type
/ People IF $luta
4 Coes / Showers
# Urinals ♦Nater Coolers
IF FOODSERVICE: t $eats Estimated Nater Usage 4 (gallons per day)
7. Typm of water supply:`��•
X coaly/City tTgNell ❑Community '
e. Do you anticipate additions or expansions of the facility this system is intended to serve! ❑ Yes
❑ No
H Yes, what type!
PBELO
RTANr**CLIE14TSAfUSTCOAIPLE7ETHE REQUIRED PROPERTY INFORMATION REQUESTED
Either a PLAT orSITE PLAN AIUST RESU ITTED by theellent with THISAPPLICATION.
Propesions: o -QIRECHONS (from Mocksville) to PROPERTY:
Tax Office PIN: k 575-� -Iy ,o��a Joq// S_ �� /S
Property Address: Road Name i St in iPe %n( Ze F/- oo.
ii/ice4v�
City/zip eeer71e
If in a Subdivision provide Information, as follows: 7014
I.
Namr. _ -1U-K 16 j -
Section Block: Lot: Date Property Flagged: --- �/r eZ di •
This'is to certify that the information provided is correct to the best or my knowledge, 1 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 ehauged. I, alm, understand that Ions rleTOH Jble for all charges Incurred front
this apPRcadom 1, hereby, give consent to the Authorized Representative of the Davjq County Health Department,
to enter upon above described property located In Davie County and owned by rr 04 2y- — T h
to conduct all testing procedures as necessary to determine the site suits It �1 ru' ar� SOf ��krin
DATE SIGNATURE
THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (luclud t of the folio ing: Existing and proposed
property lines and dimensions, drvcturce, selbacks, and septic locations).
-----------------
I
Ix
U0
} Account Na
Revised DCHD (07/98),
Invoice Na 'T
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section SECTION. LOT_U
Soil/Site Evaluation
Water Supply:
Evaluation By:
On -Site Well Community
Auger•Boring Pit
Public'
Cut
SITE CLASSIFICATION; EVALUATION BY: nCAI%C lGl T
LONG-TERM ACCEPTANCE RATE: D. of OTHER(S) PRESENT: 6A
A
REMARKS:;- Gl741171✓rl CO) Z4
LEGEND
Landscape Position
R Ridge . S - Shoulder - L - Linear slope . FS - Foot slope N - Nose slope
CC - Concave slope CV - Convex slope T - TerraceFP - Flood plain H - Head slope
Texture.
S - Sand LS - Loamy sand SL - Sandy loam L - Loam SI - Sift
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 - 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
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
*tj owl
.16RAVASNOINUMUNU
Consistence
HORIZON III DEPTH
0
•
®pilo®®®®®
SITE CLASSIFICATION; EVALUATION BY: nCAI%C lGl T
LONG-TERM ACCEPTANCE RATE: D. of OTHER(S) PRESENT: 6A
A
REMARKS:;- Gl741171✓rl CO) Z4
LEGEND
Landscape Position
R Ridge . S - Shoulder - L - Linear slope . FS - Foot slope N - Nose slope
CC - Concave slope CV - Convex slope T - TerraceFP - Flood plain H - Head slope
Texture.
S - Sand LS - Loamy sand SL - Sandy loam L - Loam SI - Sift
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 - 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
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