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APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT iD U IS
Davie County Health Department D
Environmental Health Section JUL 2 0 XM
P. O. Box 848
Mocksville, NC 27028
(704)634-8760 ENVIRONMENTAL HEALTH
DAVIE COUNTY
****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSED UNLESS
/ALL THE REQUIRED INFORMATION IS PROVIDED.
1. Name to be Billed P"i"�J U v `�r`��U Contact Person
Mailing Address PO BOX 6,)— 7 Home Phone '/
City/State/Zip (oQ leenty� 'vv `�7oi 4- Business Phone ;W— 255/
2. Name on Permit/ATC if Different than Above
Mailing Address
3. Application For:
4. System to Serve:
5. If Residence:
❑'Dishwasher
6. If Business/Other:
# Commodes
If Foodservice:
❑ Site Evaluation
❑ House V Mobile Home
# People
City/State/Zip /
El Improvement Permit & ATC lr Both
❑ Business ❑ Industry
# Bedrooms 3
❑ Garbage Disposal (S Washing Machine ❑ Basement/Plumbing
Specify type # People _
# Showers # Urinals
# Seats Estimated Water Usage (gallons per day)
❑ Other
# Bathrooms
❑ Basement/No Plumbing
# Sinks
# Water Coolers
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
lYniNo
If yes, what type?
REQUIRED: ***
Property Dimensions: 5 ae,-e
Tax Office PIN: # 5 7 *5 O- 1 <I
Property Address: Road Name 1 K4.,f"�h a-PJJn 624 7 p
City/Zip
If in Subdivision provide information, as follows:
Name:
Section: Lot #:6 dLJ
SUBMITTED WITH THIS APPLICATION.
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 q f/I t ' ful,42 'Ad
onduct all testing procedures
as necessary to determine the
site suitability.
DATE ✓� t% ,U SIGNATURE
Revised DCHD (06-96)
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IRS 221.50'
221.50'
Total
428.52'
Part of Tax Lot 16.
Parcel 1
Total Area: 5.001 Acres +/-
Note: 3.5 AcresofParcel 1 Zoned Indust)
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813.83' Total S 02°43'20"W
592.33'
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Part of Tax Lot 16
Parcel 2
Total Area: 5.098 Acres +/-
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N 02"43'20"E 337.38' IRS `?
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Part of Tax Lot 16. 3
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Parcel 3Iy p /Tax Lot
Total Area: 5.027 Acres +/-5 ti 'b t , Tax Map 1
vv II 2 n/f Roger P.
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To�01 Area: 5.022 Acres +/- IRS IRS
125.00'
S 83°46'55"W
N 03°44'15"E 669.40'
259.51' IRS
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Tax Lot 16
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DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section SECTION iOTI:?4 f
Soil/Site Evaluation
APPLICANT'S NAME DATE EVALUATED
PROPOSED FACILITY PROPERTY SIZE
SUBDIVISION _ ROAD NAME %
Water Supply: On -Site Well Community Public
Evaluation By: Auger Boring Pity Cut
FACTORS _ 1_ 2 .. 3 4 5 6 7
Landscape position ' (�
HORIZON I DEPTH
Texture group
Consistence
Structure .
Mineralogy
r HORIZON II DEPTH
Texture group
Consistence r 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: '- - * EVALUATION BY:
LONG-TERM ACCEPTANCE RATE: , y 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(01-90)