123 Cooks Trail Lot 4A�� ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
jJ �5!' IS VALID FOR A PERIOD OF FIVE YEARS
ENVIRONMENTAL HEALTH SPIALIST.' DATE ISSUED {'.
DCHD OSA6 (Revfscd) -,
r" APPLICATION FOR SITE EVALUATIONAMPROVEMENT PERMIT M
Davie County Health Department D V
Environmental Health Section
P. O. Box 848 JUL 2 Q IM
Mocksville, NC 27028
(704)634-8760
****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSED
ALL THE REQUIRED INFORMATION IS PROVIDED.
Name to be Billed LV�l1% Contact Person
Mailing Address PO00xp�Oa 7 Home Phone �0p"
City/State/zip -"' wD�evr ilX.e !UG of 7DI 7 Business Phone '20 1' 255
2. Name on Permit/ATC if Different than Above
Mailing Address City/State/Zip-
3. Application For: ❑ Site Evaluation ❑ Improvement Permit & ATC LH' Both
4. System to Serve: ❑ House . ❑ Mobile Home ❑ Business 20 Industry ❑ Other
5. If Residence: # People # Bedrooms # Bathrooms 2
l/Dishwasher ❑ Garbage Disposal 12/ 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: ElCounty/City. U Well ❑ Community
8. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes 3 niNo
If yes, what type?
PROPERTY
P——rt Dimensions:
A PLAT OF THE PROPERTY MUST BE
SUBMITTED WITH THIS APPLICATION.
P 1
1
Tax Office PIN: # 7-11S ��IXOq
ry X�s 2oaA'?� 1
1
Property Address: Road Name 1
,^,II//nn IInnnn ^� (� 1
City/Zip �oc'koIC& 0?Qo2.d 1
1
1
If in Subdivision provide information, as follows: 1
1
Name: 1
1
Section: Lot #: 1
1
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 --7-2-046 SIGNATURE
Revised DCHD (06-96)
testing procedures
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Parcel 1
Total Area: 5.001 Acres +/-
Note: 3.5 Acres of Parcel 1 Zoned lndustr.
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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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Parcel 3
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Total Area: 5.027 Acres +/-
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foul Area: 5.022 Acres +/-
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DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
APPLICANT'S NAME 'S W
PROPOSED FACILITY
SUBDIVISION ,
SECTION LOT%fi
DATE EVALUATED
PROPERTY SIZE
ROAD NAMEd///��/✓/ i
Water Supply:
Evaluation By:
On -Site Well
Auger Boring Ja�'__
Community
Pit
Public
Cut
L/
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N@bU:j
����l�s®®sem
HORIZON IV DEPTH
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Consistence
Structure
ROW Ica 1:1 114eli W_XWN
SITE CLASSIFICATION:' EVALUATION BY:
LONG-TERM ACCEPTANCE RATE: OTHERS) 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, SII., - 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
nCM (oi-sa)