111 Cummings Lane Lot 8B11722.,
DCHD 05/96 (Revised)
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APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT i fns ff22 M
Davie County Health Department D FSEP
Environmental Health SectionP.O. Box 898/210 Hospital street2 3 1998
Mocksville, NC 27028
(336)7S1-8760
***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS L-THE-RE(ZU RED
INFORMATION IS PROVIDED. CRefer to the INFORMATION BULLETIN for instructions.
1. Name to be Billed 1206E - i...)1 JI lI nif o Contact Person
Mailing Address <}' 3 Some Phone g-,7(49
_310 �LS `-t
City}state/ZIP ool D 0 r i,— r\ ` ) aq 0 1 Business Phone
2. Name on Permit/ATC if Different than Above -1
Nailing Address City/State/Zip /
3. Application For: ❑ Site Evaluation 11 Improvement Permit/ATC oth
4. system to service: ❑ House •.9 -Mobile Home ❑ Business ❑ Industry ❑ Other'
S. If Residence: # People i Bedrooms 13# Bathrooms C�-
O Dishwasher D Garbage Disposal XNashing Machine 0 Basement/Plumbing ❑ Basement/No Plumbing
6. If Business/Industry/Other: Specify type i People ♦ Sinks
N Commodes M Showers i Urinals
Nater Coolers
IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day)
7. Type of water supply: ❑ County/City ❑ Well ❑ Community
a. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes CP40
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" IMPORTA " CLIENTS MUST COMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED
BELOW. Either a P1/LAT or SITE PLAN DIUST BESURWITED by the client with THIS APPLICATION.
Property Dimensions: / 2 5� C
r1 vv� p WRITE DIRECTIONS (from Mocksville) to PROPERTY:
Tax Once PIN: # / 1 S//601 0 0'^' ,QQ'4611EP
Property Address: Road Name / °( I/(7il"1/�� JI���O KtY
City/Zip a ! 6 g b
If in a Subdivision provide information, as follows:
Name:
Section: Block: Lot: D
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. I, hereby, give consent to the Authorized Representative of the Davte,�ounty Healtkpepartment
to enter upon above described property located in Dane County and owned by /CPQ, Q d' jn cZ l7
to conduct all testing procedures as necessary to determine the site suitability. a
DATE V< SIGNATURE
THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN:
gcaf. -
No. 4
rlp3p!��uli.Ntl �i
Invoice No. a(
Revised DCHD (07/98)
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813.83' Total S 02°43'20"W
S 7?°51'00"E \
17.88'
"Buggy" Axle Found
P 592.33 IRS
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- Centerline Proposed 60' Access Easement Sea Call Table
— _ IRS N 02°43'20"E 314.5E' IRS /
11
01` Tax Lot 16 N 65°;')'45"W /
Parcel 2 64. ;9'
-ea: 5.09b Acres
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RS ^� l
/oa Iax Lot 16 y
Tax Map M-5 y /
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'Jb Z n/f Roger P. Spillman j
DB 190 0 PC 101
P10 Parcel 7 O
3 15 /
00'
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,IDS CegjeNine ..� ` Vm
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Te Line j46.9 f ,
IRS
Tax Lo} 16
Tax Map M-5
n,If Roger P. Spillman
DB 190 4 PC 101
P/0 Parcel 8 -B
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125-00' / See Ca„ iable $ t °Cess Ease, ofr
83°46'55"W t 1 05�
IRS
Tax Lot 16
Tax Map M-5
n/f Roger P. Spillman Cb ? Tax i of 16
DB 190 O PO 101 01 Tay p M-5
1 n/f Roger P. Spillman
arc,l , 1 DB 1S0 ` PC 101,,
(area: acr=s +i ) 1 m Pu al 8 1n/J
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t7, C1
1 m`
ix Lot 16 b !
15 a
931 Acres
1 �1
1 1�
Pi��mcth sl
1 1
j 119.22' 1 1
S 03"56'35"W IRS 112" EIR Ti: Line
1/2" EIR 1/2" c7F', N 0 ,'24'05"E 255.67'
00
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00
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ti
N
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5.70'
►5F
1201.1
N 83
1/2" EIR
S 05°24'05"W
119.89,
Tie Line
"Sallie Acres"
Sheet 2 of 2 "Sallie Acres"
PB 6 0 PC 160 I Sheet 2 of 2
PB 6 O PC 160
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DAVIE COUNTY HEALTH DEPARTMENT
Environmental.Health Section SECTioN ' LOT_
Soil/Site Evaluation
APPLICANT'S NAME W ���'C— t L �+�A� DATE EVALUATED i2t, j_c7—'�
PROPOSED FACILITY M AMC, PROPERTY SIZE (�t��f
t SUBDIVISION ROAD NAME ,' �ll'A-1 AE1.S
Water Supply:, On -Site Well Community Public d�
Evaluation By: Augei Boring Pit Cut
SITE CLASSIFICATION: Y 3 jj . EVALUATION BY: <�.l-rti3�7Ltla 1
LONG-TERM ACCEPTANCE RATE:.. O.'T 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
CONSISTENCE
ist
VFR -. Very friable FR - Friable FI - Firm VFI - Very firm EFI - Extremely firm
Wet .
NS - Non sticky SS = Slightly stickyS = 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)
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Consistence
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SITE CLASSIFICATION: Y 3 jj . EVALUATION BY: <�.l-rti3�7Ltla 1
LONG-TERM ACCEPTANCE RATE:.. O.'T 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
CONSISTENCE
ist
VFR -. Very friable FR - Friable FI - Firm VFI - Very firm EFI - Extremely firm
Wet .
NS - Non sticky SS = Slightly stickyS = 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)
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