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107 Cooks Trail Lot 7A2mit DOES OR WAST fi of a syste i.S. Chapte ... AULILLITI �.,t;PL.4NS ORTllEl[r%lmWED USE CHANGE. YOUR WASTEWATER r-11: �DATtISS &ED,n,.:,:7, SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE,,' ? APPLICATION FOR SITE EVALUATION/IMPROVEMENir PERMIF & A Q p' I5 Davie County Health Department EnvironmenfaiHealtb Section P.O. Box 848/210 Hospital Street SCr[n 2 3 1998 IN Mocksville, NC 27028 (336)751-8760 ENVIRONMENTAL HEALTH DAVIE COUNTY ***nWORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions 1. Name to be Billed eO CM --e- 0 i( 6 A n Contact Person 'O Q Pdb Nailing Address P -0-0) 3S Rome Phone ��ZLL a^B�q X747 . City/state/ZIP oaf 9. Op �� '� /1i91�_ Business Phone L CgL-J -/ - 2. Name on Permit/ATC if Different than Above Mailing Address City/State/21p 3. Application For: ❑ Site Evaluation ❑ Improvement Permit/ATC ...Both 4. system:to service: ❑ House U Mobile Home ❑ Business ❑ Industry ❑ Other 5. If Residence: i People 4 f Bedrooms 3 # Bathrooms ;2- 11 11 Dishwasher 0 Garbage Disposal 11 Hashing Machine D Basement/Plumbing D Basement/Mo Plumbing 6. If Business/Industry/other: Specify type # People # sinks # Commodes # Showers # Urinals #rater coolers IF FOODSERVICE: F Seats Estimated Water Usage (gallons per day) 7. Type of water supply: ❑ County/City ❑ Well ❑ Cczmur_ity S. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes JNi(0 " IMPORTA " CLIENTS AIUST COMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN /7AIUST RESUBMITTED by the client with THIS APPLICATION. Property Dimensions: Y2 '' I� �Iq �i 5 6 9 gar WRITE D Cf1ONS (from Mocksville) to PROPERTY: Tax Office PIN: # ,/y� f Q}� , CIO�/�a.�� Property Address: Road Name "f ? ( i ("k cityaip aqo� g If in a Subdivision provide information, as follows: Name: Section: Block: Lot: / 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, understand that I am responsible for all charges incurred from this application. /, hereby, give consent to the Authorized Representative of the DaVq County Health epanSn e t to enter upon above described property located in Davie County and owned by I {� to conduct all testing procedures as (necessary to determine the site suit ' ity. DATE SIGNATURE THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN: -a4ppli� No. of Invoice No. '+ / Revised DCHD (07/98) S 7?°51'00"E 17.88' 813.83' Total S 02°43'20"W "Buggy" Axle Found P 592.33' - z7P 4— L-7 �— Centerline Proposed 60' Access Easement See Call Table IRS N 02°43'20"E 314.5E' IRS / of Tax Lot '16 N 65°i')'45"W / Parcel /Q 64.:9' rea: 5.096 Acres RS / / *°a fax Lot 16 I Tax Map M-5 'Jb Z n/f Roger P. Spillman 7(,r DB 190 O PO 101 P/0 Parcel 7 N J< 3a /✓� b y/, Tax Lot 16 Tax Map M-5 :� s•' A7(oOFA '� / n.If Roger P. Spillman /330' f 220 � l f�f( z� C % / DB 190 0 PO 101 00' 1 � ' / I P/0 Parcel 8 IRS ci sear 6,0, iq o (y IFS Q1 P �-- C:ent\c•/f/k Q�7 1 f' 1046'5 See Ca Tabl cess Ease nt 83°46'55' W � 1 e "1 �S FtL N 83*'. IRS � � �-�1201.1 -1 Tax Lot 16 1 b 1 Tax Map M-5 3 n/f Roger P. Spillman ? FACTORS 1 '2 3 4._ 5 6 7 Landscape position L Slope % 1Zy HORIZON I DEPTH p - A - Texture group GL - °-, GL Consistence SSP G� SS SP Structure �2 C Mineralogy HORIZON H DEPTH. _ z14 Texture group Consistence ' S Structure Mineralogy f HORIZON III DEPTH 2 - --T2- Texture Texture rou -t- Consistence Pr.S Pr Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure (z Mineralogyt ; SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION:- YDS EVALUATION BY: �G 'i—XJ�t�tF�✓�/J LONG-TERM ACCEPTANCE RATE: OTHER(S) PRESENT: REMARKS: - LEGEND Landscape Position' R - Ridge ' S - Shoulder L - Linear slopeFS - 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 Mineraloav 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) MEMO MEMO NONE 1111■■■■■ 1111■■■■■ MONSOON 1111■s■■■