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
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MONSOON
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