124 Cooks Trail Lot 2A**,*NOTICE"'THIS A1
.0 �iy 2�..••�� �I "d�, IS VA
ONMENTAL'HEAOTH SPECIALIST ; DATE ISSUED
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**NOTE** This Improvement Permit DOE
''r AUTHORIZATION FOR WA;
xonstructionfinstallation of a syi
(1n compliance with Article I.I. of CJS Chal
1.
APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT
Davie County Health Department
Environmental Health Section
P. O. Box 848
Mocksville, NC 27028
(704)634-8760
****IMPORTANT**** THIS APPLICATION CANNOT BE PRO(
ALL THE REQUIRED INFORMATION IS
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Name to be Billed K'-""' ' ' "�' ;Ket Z/6)1 401
20 6hV Z rl
Mailing Address Home Phone
i
City/State/Zip Ovo� mvj� ri" d -7O4 Business Phone 9-) y`'/ -"`56I
2. Name on Permit/ATC if Different than Above
Mailing Address City/State/Zip
3. Application For: ❑ Site Evaluation ❑ Improvement Permit & ATC loth
4. System to Serve: ❑ House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other
5. If Residence: # People # Bedrooms 13 # Bathrooms
LI/Dishwasher ❑ Garbage Disposal VWashing 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 Well ❑ Community
8. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes la'No
If yes, what type?
A PLAT OF THE PROPERTY MUST BE
SUBMITTED WITH THIS APPLICATION.
Property Dimensions: ay
1
Tax Office PIN: # 5 705 0-9 Zl8 11
Property Address: Road Name
City/Zip
1
1
If in Subdivision provide information, as v� 1
1
Name: 1
1
Section: Lot #: 1
1
WRITE DIRECTIONS (from
Mocksville) TO PROPERTY:
601 S -/V
/4No, AMII
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 P-0 I �' t ` a ef!:�:% %t conduct all testing procedures
as necessary to determine the site suitability.
e
DATE / - 2 d -qo SIGNATURE
Revised DCHD (06-96) �/
1/2" EIR
159.42'
IRS
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Marie Smith Link
08 61 O PO 38
N 02°43'20"E 942.65' Total
221.50' IP
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3 1.5 Acres Portion ;
v of Parcel 1 Zoned RIA
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IRS 221.50'
428.52'
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
592.33'
.— L-7
P - -
Centerline Proposed 60' Access Easement S
__ __ __ —
IRS N
Part of Tax Lot 16
Parcel 2
Total Area: 5.098 Acres
N 02°43'20"E 337.38' IRS h
IRS
v
" 3
Part of Tax Lot 16.
Parcel3o I Tax t
Tax Mapti
Total Area. 5.027 Acres N ('Ib n Roger P.
VV IJ 2
I' CIS n/� .' G oa 190 ® F
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Part of lax Lot 16 _
Parcel 4 IRS
Tool Area: 5.022 Acres +/- � IRS
125.00'
S 83"46'55"11V
N 03°44'15"E 669.40'
259.51' �/� ;, IRS
a.
oo' �
409.89'
Tax Lot 1
Tax Map M-
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►? `DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section SECTION LOT
Soil/Site Evaluation
APPLICANT'S NAME .`a /i DATE EVALUATED
PROPOSED FACILITY. /2?A PROPERTY SIZE
SUBDIVISION ROAD NAME
Water Supply: ' On -Site Well Community Public Ll_�
'
Evaluation By: Auger Boring v Pit �! Cut
FACTORS 1 2 3 4: 5 6 7 -
Landscape position
Slope % $ 6
HORIZON I DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH 4/ "i
Texture group
Consistence
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: EVALUATION BY:
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
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 OR -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 (OIAO)
%1
i
No
ON
ON
si