2565 Davie Academy Road Lots 63,64, & 65yu`
` APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
5 Davie County Health Department (? 0 � L/�7 N
S ' Environmental Health Section
P. O. Box 665
Mocksville, NC 27028 MY ,-, `-',,,
1. Application/Permit Requested By
Mailing Address -v Re, -
Home
Home Phone 7e9 59 - s 39 - S / 7-2— Business Phone
2. Name on Permit if Different than Above
3. Application/Permit for: f' General Evaluation ❑ Septic Tank Installation
4. System to Serve: ❑ House ❑ Mobile Home ❑ Place of Public Assembly
❑ Business ❑ Industry ❑ Other ❑ Unknown
5. If house, mobile home: Subdivision 0AK lct Ne.shkS Section Lot # 4Pg'�4'�s
Q,+L
No. of People
No. of Bedrooms
No. of Bathrooms
Dwelling Dimensions
6. If business, industry, place of public assembly, other: Specify type
No. of People Served
No. of Sinks
Ru —Ii-
❑ g
Basement/Plumbing
❑ Basement/No Plumbing
❑ Washing Machine
❑ Dishwasher
❑ Garbage Disposal
No. of Commodes No. of Urinals
No. of Lavatories No. of Water Coolers
No. of Showers Water Usage Figures
7. Type of water supply: ❑ Public ❑ Private
8. Property Dimensions Sewage Disposal Contractor
9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes ❑ No
If yes, what type?
❑ Community
'NOTE: Improvements Permits shall be valid for a period of 5 years from date issued. Improvements Permits are subject to
revocation, if site plans or the intended use change. Effective October 1, 1989.
Directions to Property: `k w - \ ke- F } a�- CA -1 Kl s - JEAS
T (�
E) h)L\ct,Q �\t' <%&S
a,o K�r t. o o ( e rlo,-r
A%-� Cc'... --b P��,�-J .
This is to certify that the information provided is correct to the best of my knowledge, and I understand I
incurred from this application.
X .SS— 21- \ L -71-
DATE SIGNATURE
responsible for all charges
CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY
Fand
ECK ONE: 2.1.1 OWN the property. ❑ 2. 1 DO NOT OWN the property.
ked Box #2, the rest of this form MUST be completed by the owner or a person authorized by the owner:
ve consent to the authorized representative of the Davie County Health Department to enter upon above described
cated in Davie County and owned by
all testing procedures as necessary to determine said site's suitability for a ground absor tion sewage treatment
al system.
DATE SIGNATURE
DCHD (12-90)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
NAME ���'�lr DATE EVALUATED���':�
ADDRESS PROPERTY SIZE�Ae
PROPOSED FACIILTY LOCATION OF SITE Vi•�i�f';r��� y�
Water Supply: On -Site Well Community Public
Evaluation By: Auger Boring 4'-- Pit Cut
FACTORS 1 2
3 4
Landscape position
Slope % — —
HORIZON I DEPTH
Texture group
Consistence
Structure
MineralogX
HORIZON II DEPTH
Texture group
Consistence
Structure
Mineralogy
r, -
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 c
SITE CLASSIFICATION: 9
LONG-TERM ACCEPTANCE RATE:
REMARKS:
DCHD (01-901
EVALUATED 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
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
. Davie County Nealth' De artment
and .dome NealtFi
9en
cy
210 HOSPITAL STREET/ P.O. BOX 665
MOCKSVILLE, N.C. 27028
PHONE: (704) 634-5985
May 29, 1992
James Thomas Gaither
Rt. 1, Box 150
Olin, NC 28660
Re: Site Evaluation
Oakland Heights/Lot 63-64-65
Dear Mr. Gaither:
As requested, a representative from this office visited the aforementioned
site on May 28, 1992. The site was found provisionally suitable for the
installation of a ground absorption sewage system.
If you have any questions, please feel free to contact this office.
Sincerely,
Robert B. Hall, Jr., R.S.
Environmental Health Section
RH/wd
Enclosure