150 Wilson Trail Lot 5BAPPLICATION FOR SITE EVALUATION/IMPROVEMENT P Tgz ,&E Q T l5
` e Davie County Health Department D
\V Environmental Health Section
E O. Box 848 JUL 2 0
Mocksville, NC 27028
�1J (704) 634-8760 ENVIRONMENTAL HEWN
rr
DAY COUNTY
****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSED UNLESS
j� ALL THE REQUIRED INFORMATION IS PROVIDED. {� n
1. Name to be Billed pKfj %�[ Contact Person
Mailing Address l //V11 ll /"J � � Home Phone �IJ�j,{ r °� 7U7
City/State/Zip rho � `ILS � / � Business Phone a2 1 • 2561
2. Name on Permit/ATC if Different than Above
Mailing Address City/State/Zip
3. Application For: ❑ Site Evaluation ❑ Improvement Permit & ATC M'� Both
4. System to Serve: ❑ House ❑ Mobile Home ❑ Business rte❑ Industry ❑ Other
5. If Residence: # People # Bedrooms # Bathrooms
11Y6ishwasher ❑ Garbage Disposal 39�Washing Machine ❑ Basement/Plumbing ❑ Basement/No Plumbing
6. If Business/Other: Specify type # People # Sinks
# Commodes # Showers # Urinals # Water Coolers
If Foodservice: # Seats - Estimated Water Usage (gallons per day)
7. Type of water supply: ❑ County/City U Well ❑ Community
8. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes 3 No
If yes, what type?
INFORMATION REQUIRED:
A PLAT OF THE PROPERTY MUST BE
SUBMITTED WITH THIS APPLICATION.
Property Dimensions: GY f/ 1 WRITE DIRECTIONS (from
�
5 0 9 2/ 1 Mocksville) TO PROPERTY:
Tax Office PIN: # / 4 u 1
1 /�i/L�YIQp 1
Property Address: Road Name QAC -/fin
city/zip
1
If in Subdivision provide information, as follows: 1
Name: 1
Section: Lot #: 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 Representativeof
the Davie County] HealthDepartmentto anter upon above described property located in Davie County
and owned by " ""� � o -2 -'j - G✓!/_ /�7 3 to conduct all testing procedures
as necessary to determine the site suitability.
DATE -7 2 0 —qitSIGNATURES
Revised DCHD (06-96)
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262
IRS
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N 03°44'15"E 669.40' IRS
259.51'/ y IRS �. 409.89'
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Part of Tax Lot 16 g
m Parcel 5 rn
Total Area: 5.931 Acres +/-
Tax Lot 16
Tax Map M-5
n/f Roger P. Spillman
OB 190 O PG 101
Parcel 7
(Area: 8.4 Acres +/-)
Part of Tax Lot 16 m - p
Parcel 6 R042v SPI Nvn l N
Total Area: 6.212 Acnes +/-
IRS 119.22'
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S 03.56'35"W IRS
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to 60.00' ~ Sheet 2 of 1
0!01''r PB 6 O PC 160
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P N 66'19'05"E N
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PropnW 60• A�,.•• Ease -Ont I 226.70'
g S 06.5435'W 1/2" OR
IRS 361.10' S 06.54'J,5"W 8 _ — — — — — —
�•� aaar _--_________IRS 19.25'
— IRS- - - - - - -- -
----------------------
------- ---- ---- -- ---- ---- — - -- - -- --- - - -- - - -- -
/ Michaels Boa
l - / 60' Public R/W 1
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HORIZON II DEPTH r
Texture group
-Consistence
Structure <
Mineralogy
HORIZON III DEPTH -
Texture group
SITE CLASSIFICATION: EVALUATION BY:
LONG-TERM O ACCEPTANCE RATE:
- e 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
,
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
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 (0490)
■iii®®®®
SITE CLASSIFICATION: EVALUATION BY:
LONG-TERM O ACCEPTANCE RATE:
- e 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
,
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
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 (0490)
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