157 Wilson Trail Lot 6ADCHD 05* (Revised) -
APPLICATION FOR SITE EVALUATION/IMPROVEMENT
Davie County Health Department
Environmental Health Section
E O. Box 848
Mocksville, NC 27028
(704) 634-8760
**** TA **** THIS APPLICATION CANNOT BE PROCESSED UNLESS 929:
ALLTHE REQUIRED INFORMATIONIS PROVIDED. /�
1. Name to be Billed - - �iii`� _- Contact Person
Mailing Address
City/State/Zip
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2. Name on Permit/ATC if Different than Above
Mailing Address
3. Application For:
4. System to Serve:
5. If Residence:
❑Xshwasher
City/State/Zip
Home Phone
Business Phone o"J' -2L
❑ Site Evaluation ❑ Improvement Permit & ATC GY Both
❑ House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other
# People # Bedrooms J7 # Bathrooms
Cl Garbage Disposal Washing Machine ❑ Basement/Plumbing ❑ Basement/No Plumbing
6. If Business/Other: Specify type
# Commodes
# Showers
# Urinals
# People # Sinks
# Water Coolers
If Foodservice: # Seats Estimated Water Usage (gallons per day)
7. Type of water supply: ElCounty/City &-/Well ❑ Community
8. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes Q No
If yes, what type?
PROPERTY
Property Dimensions:
5ae, 4-
C *** A PLAT OF THE PROPERTY MUST BE
SUBMITTED WITH THIS APPLICATION.
Tax Office PIN: # / y'i 5- 0 q m 3219
Property Address: Road Name I !�1^y t/,a& n(n dC
city/Zip / / 1 0CAJ o iK'& a--�Oa-
If in Subdivision provide information, as follows:
Name:
Section: Lot #:
WRITE DIRECTIONS (from
Mocksville) TO PROPERTY:
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 Health Department to enter upon above described property located in Davie County
and owned by
as necessary to determine the site suitability.
/D
DATE -7-219 -IfSIGNATURE
Revised DCHD (06-96)
conduct all testing procedures
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Total Area: 5.931 Acres +/-
Part of Tax Lot 16 �, D
Parcel 6 !1 O q ev s p l I m g h
D. Total Area: 6.212 Acres +/-
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Tax Map M-5
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DB 190 O PG 101
Parcel 7
(Area: 8.4 Acres +/-)
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DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
APPLICANT'S NAME;
i PROPOSED FACJLITY �2
SUBDIVISION
SECTION LOT
DATE EVALUATED /� I
PROPERTY SIZE l
ROAD NAME % t
Water Supply:
On -Site Well
Community
Publicy
Evaluation By:
Auger Boring
Pit L'11�
Cut
FACTORS
1 12 3 4 5 6 7
Landscape position
Slope %
HORIZON I DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH
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
SITE CLASSIFICATION:��'
LONG-TERM ACCEPTANCE RATE: t
REMARKS:
DCHD (01-90)
EVALUATION BY:'
OTHER(S) PRESENT:
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