132 Cooks Trail Lot 2BRBAGEDISPOSAL::Yes:dr.No I
DljSTRIA,LwjkSTE:yisorNo
r APPLICATION FOR SITE EVALUATIONAMPROVEMENT
Davie County Health Department
Environmental Health Section
P. O. Box 848
Mocksville, NC 27028
(704) 634-8760
****IMPORTANT**** THIS APPLICATION CANNOT BE ]
ALL THE, REQ_UIJREEDD INFORMATI(
1. Name to be Billed ( tom✓ / t /
Mailing Address � � �A 7
City/State/Zip CZ0 tUAI & 4e, 0?
2. Name on Permit/ATC if Different than Above
Mailing Address
3. Application For: ❑ Site Evaluation
D
WINUMT4.1
J IS �OjLIDED.
f ��C�
C tact Person �p
Home Phone did 'q'7
Business Phone 21?11 —255 f
City/State/Zip
❑ Improvement Permit & ATC ("Both
4. System to Serve: ❑ House ❑ Mobile Home ❑ Business 2❑ Industry
5. If Residence: # People / # Bedrooms
f� Dishwasher ❑ Garbage Disposal 2 Washing Machine ❑ Basement/Plumbing
6. If Business/Other: Specify type
"# Commodes
If Foodservice:
7. Type of water supply:
# Showers
# Urinals
❑ Other
# Bathrooms Z
❑ Basement/No Plumbing
# People # Sinks
# Seats Estimated Water Usage (gallons per day)
❑ County/City , 51 Well .
# Water Coolers
❑ Community
8. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes CY No
If yes, what type?
Property Dimensions:
56L '
IMPORTANT *** A PLAT OF THE PROPERTY MUST BE
SUBMITTED WITH THIS APPLICATION.
Tax Office PIN: # '57L -1'J - ,0- r ��v
Property Address: Road Name } (tX h o o6 6 o oc p
City/Zip ��) ��` c2-702,9
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.
DATE -7,20 - 98 SIGNATURE
Revised DCHD (06-96)
conduct all testing procedures
lq"f. /J�o
4v, / g6
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section SECTION LOT& .
Soil/Site Evaluation
APPLICANT'S NAME`/%l/
PROPOSED FACILITY �L7
SUBDIVISION
DATE EVALUATED ` lD
PROPERTY SIZE may/ �a2 3r�c
ROAD NAME
Water Supply:
On -Site Well
Community
Public
Evaluation By: ,
Auger Boring
Pit
Cut
FACTORS
1 -2 3 4 5 6 7
Landscape position
J/
Sloe %
4/rio -1/026
HORIZON I DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH
i ,/-
Texture group
Consistence
Structure.
Mineralogy
A
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
SITE CLASSIFICATION: EVALUATIONBY:'A/lb
LONG-TERM ACCEPTANCE RATE: 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
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
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(0)-90)
1/2" EIR
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N 02°43'20"E 94,2.65' Total
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Part of Tax Lot 16
Parcel 1
Total Area: 5.001 Acres +/-
Note: 3.5 Acres of Parcel 1 Zoned Industr.
813.83' Total S 02"43'20"W
IRS 221.50' P 592.33'
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— _ — — � Centerline Proposed 60' Access Easement S,
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Parcel 2
Total Area: 5.098 Acres +/-
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N 02°43'20"E 337.38' IRS h
IRS
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Part of Tux Lot 16.
j�Tax Lot
Parcel 3 Iy 5, o I � Tax Map X,
Total Area: 5.027 Acres +/- N ' n f Roger P.
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Total Area: 5.022 Acres +/- � IRS
125.00'
S 83"46'55"'W
N 03°44'15"E 669.40-
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409.89'
Tax Lot 16
Tax Map M—