144 Wilson Trail Lot 5A,oil lTHORiz aGN No 1 s DAVIE OUNTY HEALTH DEPARTMENT Pd q -ZS
x >rc i Environmental Health Section
PROPERTY INFORMATION,
Permittees
. `, \ /�.�- P.O. Box 848
Name CAG1 @I*' d I/YJ.S'i4/ 141ocksville; NC 27028 Subdivision Name:
1.
Phone # 336-751-8760
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Directions toproperty; J��+ f /✓ Section: Lot:
FOR
WASTEWATER
SYSTEM CONSTRUCTION Tax Office PIN:#
�C%�p
Road Name / <' ^ p>
**NOTE** This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental. Health Section prior
to issuance of any Building-P.emtits. This Form/Authorization Number should be presented to the Davie County.Building Inspections .
Office when applying for Building Permits
(In compliance with Article 11 of G.S. Chapter 130A, )Vastewater; Systems, Section .1900Sewage Treatment and Disposal Systems)
l J ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
/C%�„ IS VALID FOR A PERIOD OF FIVE YEARS. -
ENVIRONMENTAL!HEALTH SPECIALIST' ..DATE ISSUED, _ -
APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMI
d
Davie County Health Department
Environmental Health Section JUL 2 0 1998
P. O. Box 848
Mocksville, NC 27028
(704) 634-8760 ENVl 0NN1 milnm�
****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSED UNLESS
�/�/� �7 Sh
ALL
��THE REQUIRED INFORMATION IS PROVIDED.
1. Name to be Billed ' ,06" k U/GI��1/ I t ' `A tJ Contact Person W �� /_
Mailing Address t" 0 8W / 0 Home Phone a " ? ` -7
City/State/Zip Coolanut Iv� /�'� Business Phone '1Z9q-"2-65L
2. Name on Permit/ATC if Different than Above
Mailing Address
City/State/Zip
Property Dimensions:
3. Application For:
❑ Site Evaluation ❑ Improvement Permit & ATC
l/Both
4. System to Serve:
❑ House ❑
Mobile Home ❑ Business ❑ Industry
❑ Other
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Property Address: Road Name t I l�(/VItiX
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a
5. If Residence:
# People
# Bedrooms
# Bathrooms
Li' Dishwasher
❑ Garbage Disposal
U/ Washing Machine ❑ Basement/Plumbing
❑ Basement/No Plumbing
6. If Business/Other:
Specify type
# People
# Sinks
# Commodes
If Foodservice:
7. Type of water supply:
# Showers
# Urinals
# Seats Estimated Water Usage (gallons per day)
❑ County/City 2Well
# Water Coolers
❑ Community
8. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes Wr"No
If yes, what type?
REQUIRED:
A PLAT OF THE PROPERTY MUST BE
SUBMITTED WITH THIS APPLICATION.
Y
�L
Property Dimensions:
1 WRITE DIRECTIONS (from
Tax Office PIN: #
Mocksville) TO PROPERTY:
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Property Address: Road Name t I l�(/VItiX
K(it
1 '
1 yM//OLA 86(
1I owu
City/Zip
If in Subdivision provide information, as follows:
1
1
1
Name:
1
1
Section: Lot #:
1
1
1
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 Davie County
nHealth Department to enter upon above described property located in Davie County
and owned by to conduct all testing procedures
as necessary to determine the site suitability.
c
DATE / —20 �qq S
Revised DCHD (06-96)
IRS N 03°44'15"E 669.40' IRS
259.51' IRS 409.89'
moo:
F` l Oe Tax Lot 16
I� Tax Map M-5
T o n/f Roger P. Spillman
(� DB 190 O PG 101
Parcel 7
(Area: 8.4 Acres +/-)
14 m
rii
y �N 41'
Part of Tax Lot 16 01
ri' Parcel 5 m
Total Area: 5.931 Acres +/-
Part of Tax Lot 16 m Q
Parcel 6 " 0� ev S p M"Ct ►k
3
Nf Total Area: 6.212 Acres +/-
ol
"I (91 9-v- Sp�L�Yna
z IRS \ 119.22'
S 03.56'35"W IRS
1/2" OR
CO
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l00
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n, IISa
"llie Acres"
CO so.00
rn Sheet 2 of 2
N ot•11.33•'w `� PB 6 O PG 160
O
P N 88r'48'048'0 3"E N
P
Propoeed 60' Accem Easement 226.70'
g S 06°54135, W
IRS 1/2" EIR
361. 10' S 06.54'35"W—
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IRS _ -IRS 19.25'
� 60.6I• __________________________
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DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section SECTION LOTA
Soil/Site Evaluation
APPLICANT'S NAME /
PROPOSED FACILITY %
SUBDIVISION
DATE EVALUATED'_
PROPERTY SIZE
ROAD NAME
Water Supply:
On -Site Well
Community
.Public >/
Evaluation By:
Auger Boring ✓
Pit
Cut
Texture group
Consistence
Structure
Mineralogy
HORIZON 11 DEPTH
FACTORS
1 2 3 4 5 6 7 -
Landscape position
L
Slope %
HORIZON I DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON 11 DEPTH
y
Texture group
Consistence
r
Structure
Mineralogy
HORIZON III DEPTH
Texture group
Consistence
Structure
Mineralogy.
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE
i r
SITE CLASSIFICATION: EVALUATION BY:
LONG-TERM ACCEPTANCE RATE: I 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 loamL - 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 - Finn VFI - Very firm EFI - Extremely firm '
et
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
DceD(01-90)
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