2084 Farmington Rd Davie County,NC Tax Parcel Report Wednesday, February 15, 2017
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WARNING: THIS IS NOT A SURVEY
_ Parcel Information_
Parcel Number: C50000006401 Township: Farmington
NCPIN Number: 5843800390 Municipality:
Account Number: 8304138 Census Tract: 37059-802
Listed Owner 1: SIMON SARAH N Voting Precinct: FARMINGTON
Mailing Address 1: 526 S STRATFORD RD Planning Jurisdiction: Davie County
City: WINSTON SALEM Zoning Class: DAVIE COUNTY R-A,R-20
State: NC Zoning Overlay: DAVIE COUNTY QD
Zip Code: 27103 Voluntary Ag.District: No
Legal Description: 26.691 AC FARMINGTON RD Fire Response District: FARMINGTON
Assessed Acreage: 26.69 Elementary School Zone: PINEBROOK
Deed Date: 4/2004 Middle School Zone: NORTH DAVIE
Deed Book/Page: 2004EO110 Soil Types: MrC2,EnB,irB
Plat Book: 12 Flood Zone:
Plat Page: 60 Watershed Overlay: DAVIE COUNTY
Building Value: 556470.00 Outbuilding&Extra 4590.00
Freatures Value:
Land Value: 255900.00 Total Market Value: 816960.00
Total Assessed Value: 816960.00
161 All data Is provided as is without warranty or guarantee of any kind either expressed or Implied Including but not limited to the
Davie County, Implied warranties of merchantability or fitness for a particular use.All users of Davie County's GIS website shall hold harmless theCounty of Davie,North Carolina,Its agents,consultants,contractors or employees from any and all claims or causes of action due to NC or arising out of the use or Inability to use the GIS data provided by this website.
OPERATION PERMIT or ficeuseunlV
Davie County Health Department *CDP File Number 157639-1
210 Hospital Street CS-=00064
P.O.Box 848 County ID Number.
Mocksville NC 27028 Evaluated For NEW
Phone:336-753-6780 Fax:336-753-1680 Township:
Applicant: Sarah Simon Property Owner Maria Newsome
Address: 110 Nanzetta Way Address: 1951 Farmington Road
City: Lewisville City: Mocksville
State)Zip: NC 27023 StatefZip: NC 27028
Phone#: (336)287-2867 Phone#:
Pro a Location & Site Information
Address/Road #: ��4 Subdivision: Phase: Lot:
Farmington Road
Mocksville NC 27028 Directions
_ Structure: SINGLE FAMILY .
Hwy 158 East to Farmington Rd on left. cross Hwy
801 About 1/4 mile on right . NC Country Homes
#of Bedrooms: 4 Sign
#of People:
*Water Supply: PUBLIC
*IP Issued by. 21ao-Nations,Robert *System Classification/Description:
TYPE It A.CONV SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS)
*CA issued by: 2140-Nations,Robert
SaproliteSystem? Yes QNa
Design Flow: 4 8 0 *Distribution Type: GRAVITY-PARALLEL(eq.d-box) Pump Required?
Q Yes ( No
Soil Application Rate: 0 1 7 5
*Pre Treatment:
Drain field
rNo.
on Field a 7 4 a Sq.ft. *System Type: INFILTRATOR QUICK 4 STANDARD
n Lines 4 Installer: Frank Transou
Total Trench Length: 6 8 8 ft. Certification#: 2771
Trench Spacing: Inches O.C.
Feet O.C. *EH S: 2140-Nations,Robert
Trench Width: 3Inches
&Feet Date: 0 9 / a 3 / a 0 1 5
Aggregate Depth: inches
Minimum Trench Depth: a 4
Inches
Minimum Soil Cover. 1 a inches Approval StatusAM '
Maximum Trench Depth: a g
Inches
® Approved Q DIS2pproVed
Maximum Soil Cover. 1 6 Inches
CDP File Number 157639 - 1 Se tic Tank County ID Number P5-00000064
Manufacturer. Shoat Let.
STB: 760 Long:
Gallons: 1000
Installer. Frank Tmsou
Certification#: 2771
Date: 03 / 0 ? / x 6 1 5
THS. 2140-Nations.Robed
*Filter Brand: POLYLOK Pt.-122 With Pipe Adapter 0 9 / 2 3 / a 0 1 5
ST Marker. El Yes ® NoVM
Date:
Reinforced Tank: ❑ Yes ® No AppraralStafus
1 Piece Tank: ❑ Yes c1 No
❑ �lpprov�d❑ .Dtsapproved',o '
Pump Tank
Manufacturer. Installer.
PT: Certification#:
Gallons: THS:
Date: / / bate:
RiserSealed ❑ Yes ❑ No
RiserHeght: El Yes ❑ No (Mins in.) ; ApprovaiStatus
Reinforced 'ank: ❑ Yes ❑ Noroved❑ Dasa 'roved
PP Pp
1 Piece Tank: ❑ Yes ❑ No
Supply )Line
Pipe Size: inch diameter Installer
Pipe Length: feet Certification#:
*Schedule: *EH S:
Pressure Rated ❑ Yes ❑ No Date:
Approved fittings ❑ Yes ❑ No Approval Status
❑ Approved❑:Dlsapproved
Pump u e
Pump Type: Installer
Dosing Volume: — Gal Certification#:
Draw Down: Inches THS:
*Chairs:
Date:
Valves Accessible ❑ Yes ❑ No
Flow Adjustment Valve ❑ Yes ❑ No
Check-valve ❑ Yes ❑ No ApprrnralStatus
PVC unions [3 Yes El No ❑;Approved Disapproved
Vent Hole ❑ Yes ❑ No
Anti-siphon Hole [:1 Yes ❑ NO
CDP File Number 157639- 1 County ID Number: C5.00000064
Electric Equipment
NEMA4XBoxorEquivalent ❑ Yes ❑ No Installer:
Box 12 inches Above Grade ❑ Yes ❑ No
Certification#:
Box Adj. Pump Tank ❑ Yes ❑ NO
Conduit Sealed ❑ Yes ❑ No 'EHS:
Pump Manually Operable ❑ Yes ❑ No /
'Activation Method: Date:
:Approval Status
Alarm Audible ❑ Yes ❑ No ❑ Approved❑ Disapproved,?,;
Alarm Visible ❑ Yes ❑ No
2140-Nations,Robert
"Operation Permit completed by:
Authorized State Ag Date of Issue: 0 9 / .1 3 / a 0 1 5
Owner/Applicant Signature:
This system has been installed in compliance with applicable NC General Statutes:Article 11, Chapter 130A, Rules for
Sewage Treatment and Disposal,15A NCAC 18A .1900 et. Seq.,and all conditions of the Improvement Permit and
Construction Authorization.This property is served by a TYPE I asewage septic system.
Rule.1961 requires that a Type TYPE 11 A septic system meet the following criteria:
Minimum System Review By The Local Health Department: N/A
Management Entity: OWNER
Minimum-System InspectionlMaintenance Frequency By Certified Operator:
N/A
Reporting Frequency By Certified Operator. NIA
Rule.1961 requires that a Type IV and V septic systems designed for a home/business owner must maintain a valid contract
with a public management entity with a certified operator or a private certified operator for the life of the septic system.
Rule.1961 requires that Type VI septic systems designed for a home/business owner must maintain a valid contract with a
public management entitywith a certified operator for the life of the septic system.
Rule. 1961 (2)(e)requires a contract shall be executed between the system owner and a management ently prior to the
issuance of an Operation Permit for a system required to be maintained by a public or private management entity, unless the
system owner and certified operator are the same. The contract shall require specific requirements for maintenance and
operation, responsibilities of the owner and systems operator,provisions that the contract shall be in effect for as long as the
system is in use, and other requirements for the continued proper performance of the system. It shall also be a condition of
the Operation Permit that subsequent owners of the systems execute such a contract.
GHand Drawing 41mport Drawing
**Site Plan/Drawing attached.**
OPERATION PERMIT 1
157639 - 1
Davie County Health Department CDP File Number:
210 Hospital Street C5-00000064
P.O.Box 84s County File Number:
Mocksville NC 27028 Date:
V 4 J
Q Inch
Drawing Drawing Type: Operation Permit Scale: , O 13 A k
I I I I I I
I I
I I I
%ov' IVJ I RVLP 11VN
^AUTHORIZATION *CDP File Number 157639- 1
Davie Count Health Department C5-00000064
Y p County ID Number:
t. 210 Hospital Street Evaluated For: NEW
•, �,,. P.O. Box 848 Township:
Mocksville NC 27028 PERMIT VALID UNTIL:
Phone: 336-753-6780 Fax: 336-753-1680 0 4 / 1 6 a 0 a 0
Applicant: Sarah Simon Property Owner. Maria Newsome
Address: 110 Nanzetta Way Address: 1951 Farmington Road
City: Lewisville City: Mocksville
State/Zip: NC 27023 State/Zip: NC 27028
Phone#: (336)287-2867 Phone#:
Property Location & Site Information
Address/Road#: Subdivision: Phase: Lot:
Farmington Road
Mocksville NC 27028 Directions
Structure: SINGLE FAMILY Hwy 158 East to Farmington Rd on left. cross Hwy 801
About 1/4 mile on right . NC Country Homes Sign
#of Bedrooms: 4
#of People:
*Water Supply: PUBLIC
System Specifications
Minimum Trench Depth: a 4
Site Classification: Provisionally suitable Inches
Sa rolite S stem? Minimum Soil Cover:
p y 9 Yes O No 1 a Inches
Design Flow: 4 8 0 Maximum Trench Depth: a 8 Inches
Soil Application Rate: 0 1 7 5 Maximum Soil Cover: 1 6 Inches
`System Classification/Description: *Distribution Type: GRAVITY-PARALLEL(eq.d-box)
TYPE II A.CONY SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS) Septic Tank:
1 0 0 0 Gallons
*Proposed System: 25%REDUCTION 1-Piece: O Yes O No
Pump Required: O Yes (&No O May Be Required
Nitrification Field a 7 4 a
Sq. ft. Pump Tank: Gallons
No. Drain Lines 6 1-Piece: OYes ONo
Total Trench Length: 6 8 6 ft GPM--vs— ft. TDH
Trench Spacing: O Inches O.C.
— 9 O Feet O.C. Dosing Volume: _ Gallons
Trench Width: Inches
Feet Grease Trap: Gallons
Aggregate Depth: inches Pre-Treatment: O NSF OTS-1 OTS-II
Septic Tank Installer Grade Level Required: 01 011 0111 01V
Page 1 of 3
CDP File Number County ID Number:
❑ Open Pump System Sheet
Repair System Required:®Yes O No ONO, but has Available Space
Repair System Trench Spacing: 9 O Inches O.C.
"Site Classification: Provisionally Suitable — ®Feet O.C.
Trench Width: Inches
Design Flow: 4 8 0 _ 3R Feet
Soil Application Rate: 0 - 1 7 5 .Aggregate Depth: inches
*System Classification/Description: Minimum Trench Depth: a 4 Inches
TYPE II A.CONV SYSTEM(SINGLE-FAMILY OR 480 GPD OR Minimum Soil Cover:
LESS) 1 a Inches
Maximum Trench Depth: a 8 Inches
*Proposed System: 25%REDUCTION
Maximum Soil Cover. 1 6
Nitrification Field a 7 4 a Inches
Sq. ft.
No. Drain Lines 6 *Distribution Type: PUMP TO GRAVITY
Total Trench Length: 6 8 6 ft Pump Required: OYes O No ®May Be Required
Pre-Treatment: O NSF OTS-I OTS-II
*Site Modifications
Vo grading or construction activity is allowed in areas designated for system and repair without approval of Health Department. R'
7;
*Permit Conditions
The issuance of this permit by the Health Department in no way guarantees the issuance of other permits. The permit holder
is responsible for checking with appropriate governing bodies in meeting their requirements. R
2(
This Authorization for Wastewater System Construction shall be valid for a person equal to the period of validity of the Improvement Permit,not
to exceed five years,and may be issued at the same time the Improvement Permit issued(NCGS 130A-336(b)).If the installation has not been
completed during the period of validity of the Construction Permit,the information submitted In the application for a permit or Construction
Authorization is found to have been incorrect,falsified or changed,or the site Is altered,the permit or Construction Authorization shall become
Invalid,and may be suspended or revoked(.1937(g)).The person owning or controlling the system shall be responsible for assuring compliance
with the laws,rules,and permit conditions regarding system location,installation,operation,maintenance,monitoring,reporting and repair
(1938(b)).
Applicant/Legal Reps. Signature Required? Oyes ONo
Applicant/Legal Reps. Signature, Date:
*Issued By: 2140-Nations,Robert Date of Issue: 0 4 / 1 6 / a 0 1 5
Authorized State-Agent: Malfunction Log OYes
(9 Hand Drawing O Import Drawing
**Site Plan/Drawing attached.**
Page 2 of 3
' Davie County Health Departmenty , CDP File Number:
210 Hospital Street C5-00000064
P.O. Box 848
County File Number:
Mocksville NC 27028 Date: 04 / 16 / ,2015
O Inch
Drawing Drawing Type: Construction Authorization Scale: , O Block = ft.
Yp N/A
21)
0101%j C a
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i
c!L
Page 3 of 3
D� D7
IMPROVEMENT PERMIT For office useonly
*CDP File Number 157639-1
d" Davie County Health Department
210 Hospital Street County ID Number.
c5-00000064
P.O. Box 848
Evaluated For: NEW
Mocksville NC 27028 Township:
Phone: 336-753-6780 Fax:336-753-1680 PERMIT VALID UNTIL 4/16/2020
*NOTE TO INSPECTIONS DIVISION: Building Permits cannot be issued with this Improvement Permit.
Applicant: Sarah Simon FAddress:
er: Maria Newsome
Address: 110 Nanzetta Way 1951 FarmingtonRoad
CIRY. Lewisville Mocksville
StatefZip NC 27023 StatefZip: NC 27028
Phone#: (336)287-2867 Phone#:
Property Location & Site Information
Address/Road#: Subdivision: Phase: Lot:
Farmington Road
Mocksville NC 27028 Directions
Structure: SINGLE FAMILY Hwy 158 East to Farmington Rd on left. cross Hwy
#of Bedrooms: 4 801,About 1/4 mile on right . NC Country Homes
#of People: Sign
*Water Supply: PUBLIC
System Sipecifications
rtitial ernem
*Site Classificeation: Provisionally Suitable
Minimum Trench Depth: 2 4 Inches
Saprolite System? *Yes ONO Maximum Trench Depth: a 8 Inches
Design Flow: 4 8 0 Septic Tank: 1 0 0 0
Gallons
Soil Application Rate: 0 1 3 5 1-Piece: QYes ONO
Pump Required: OYes 0No,0May Be Required
"System Classification/Description:
TYPE II A.CONY SYSTEM(SINGLE-FAMILY OR 480 GPD OR Pump Tank: Gallons
LESS)
*Proposed System: 25%REDUCTION 1-Piece: QYes ONO
Repair System Required:@Yes ONo ONO, but has Available Space
Repair System
*Site Classification: Provisionally Suitable Minimum Trench Depth: -1 4 Inches
Soil Application Rate: 0 1 7 Maximum Trench Depth: a $ Inches
*System Classification/Description: Pump Required: QYes ONO *May be Required
TYPE II A.CONY SYSTEM(SINGLE-FAMILY OR 480 GPD OR
LESS)
*Proposed System: 25%REDUCTION
Pagel of 3
CDP File Number 157639- 1 County ID Number: c5-00000064 -
*Site Modifications ❑ Open Fill Sheet
No grading or construction activity is allowed in areas designated for system and repair without approval of Health Department.
*Permit Conditions
The issuance of this permit bythe Health Department in no way guarantees the issuance of other permits.The permit holder
is responsible for checking with appropriate governing bodies in meeting their requirements.
SitePian The Improvement Permit shall be vaild for b years from date of issue with a site plan(means a drawing not necessarily drawn to
ISOscale that shows the existing and proposed property lines with dimensions,the location of thefacility and appurtenances,the
site forthe proposed Wastewatersystetn,and the location of water supplies and surfacewaters).
Plat The Improvement Permit shall be valid without expiration with prat(means a property surveyed prepared by a registered land
d surveyor,drawn to a scale of one inch equals no morethan 60 feet,that Includes:the specific location of the proposed facility
aril appurtenances,the site for the proposed Wastewater system,and the location of water supplies and surface waters. Plat
also means,for subdivision lots approved by the local planning authority and recorded with the county register of deeds,a copy
of the recorded subdivisions platthat Is accompanied by a site plan that Is drawn to scale).
The Department and Local Health Department may impose conditions on the Issuanceand may revoke the permits for failure of
the system to satisfy the conditions,the rules,or this article This permitis subject to revocation If the site pian,pla%,or Intended
use changes(NCGS 130A-335(%The person owning or controlling the system shall be responsible for assuring compliance
with the laws,rules,and permit conditions regarding system location,'installation,operation,maintenance,monitoring,
reporting,and repair(.1838(b)j
Applicant/Legal Reps.Signature Required? OYes ONO
Applicant/Legal Reps.Signature: Date:
*Issued By: 2140-Nations,Robert Date of Issue: 0 4 1 6 2 0 1 5
Authorized State Agerr' �2 - �.—� OValid without Expiration?
@eteate CA.
@Hand Drawing Olmport Drawing
**Site Plan/Drawing attached.**
Page 2 of 3
IMPROVEMENT PERMIT 157639 - 1
Davie County Health Department CDP File Number:
210 Hospital Street C5-00000064
P.O.sox 848 County File Number:
Mocksville NC 27028 Date:
Q Inch
Drawing, Drawing Type: Improvement Permit Scale: .
()Block
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At,
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-- -PROPOS?.O--SITE....LAYOUT--.--
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-��--n�ii_rumwrw_a e_ ..•..no-•.+r. �
• a
IMPROVEMENT PERMIT For office Use Ohl
CDP FQerNumber 157639 1
• Davie County Health Department
•' County IO Number C5-000000sa
210 Hospital Street
P.O. Box 848
Evaluated For NEW
Mocksville NC 27028 Township
r
Phone:336-753-6780 Fax:336-753-1680 PERMIT VALID UNTIL: 9/18/2019
*NOTE TO INSPECTIONS DIVISION: Building Permits cannot be issued with this Improvement Permit.
Applicant: Sarah Simon Property Owner: Maria Newsome
Address: 110 Nanzetta Way Address: 1951 Farmington Road
CRY: Lewisville City: Mocksville
State/Zip: NC 27023 State2ip: NC 27028
Phone#: (336) 287-2867 .Ph ne#:
Property Location & Site Information
Address/Road#: Subdivision: Phase: Lot:
Farmington Road
Mocksville NC 27028 Directions
Structure: SINGLE FAMILY Hwy 158 East to Farmington Rdon left. cross Hwy
#of Bedrooms: 4 801 About 1/4 mile on right . NC Country Homes
#of People:
Sign
*Water Supply: PUBLIC
System Specifications
nitlal SY.s_teemm
*SItdClasstflcatlon: Provisionally Suitable
Minimum Trench Depth: a 4 Inches
Saprolite System? *Yes QtVo Maximum Trench Depth: 0 8 _ Inches
Design Flow: 4 8 0 Septic Tank: 1 0
Gallons
Soil Application Rate: 0 1 7 5
1-Piece: QYes Q No
Pump Required: QYes @No OMay Be Required
*System Classification/Description:
TYPE It A.CONY SYSTEM(SINGLE-FAMILY OR 480 GPD OR Pump Tank: Gallons
LESS)
*Proposed System: 25%REDUCTION 1-Piece: QYes 'QNo
Repair System Required:*Yes ONo ONo, but has Available Space.
Repair System
*Site Classification: Provisionally Suitable Minimum Trench Depth: 0 4 Inches
Soil Application Rate: 0 1 7 5 Maximum Trench Depth: a 8 Inches
*System Classification/Description: Pump Required: QYes ONo Q May be Required
TYPE II A.CONY SYSTEM(SINGLE-FAMILY OR 480 GPD OR
LESS)
*Proposed System: 25%REDUCTION
CDP File Number 157639- 1 County ID Number: C5-00000064
*Site Modifications ❑ Open Fill Sheet
No grading or construction activity is allowed in areas designated for system and repair without approval of Health Department. .::
7!
*Permit Conditions
The issuance of this permit by the Health Department in noway guarantees the issuance of other permits.The permit holder
is responsible for checking with appropriate governing bodies in meeting their requirements.
7!
Site Plan The Improvement Permit shall be valid for 5 years from date of issue with a site plan(means a drawing not necessarily drawn to
Q scale that shows the existing and proposed property lines with dimensions,the location of the facility and appurtenances,the
site for the proposed Wastewater system,and the location of water supplies and surface waters).
Plat The Improvement Permit shall be valid without expiration with plat(means a property surveyed prepared by a registered land
surveyor,drawn to a scale of one inch equals no more than 60 feet,that includes:the specific location of the proposed facility
O
and appurtenances,the site for the proposed Wastewater system,and the location of water supplies and surracewaters. Plat
also means,for subdivision tots approved by the local planning authority and recorded with the county register of deeds,a copy
of the recorded subdivisions plat that is accompanied by a site plan that is drawn to scale).
The Department and Local Health Department may impose conditions on the issuance and may revoke the permits for failure of
the system to satisfy the conditions,the rules,or this article.This permit Is subject to revocation If the site plan,plat,or intended
use changes(NCGS 13OA-335(i)).The person owning or controlling the system shall be responsible for assuring compliance
with the laws,rules,and permit conditions regarding system location,installation,operation,maintenance,monitoring,
reporting,'and repair(.1938(b)j.
Applicant/Legal Reps. Signature Required? OYes ONO
Applicant/Legal Reps. Signature: Date:
"Issued By: 2140-Nations,Robert Date of Issue: 0 9 1 8 2 0 1 4
OValid without Expiration?
Authorized state Agent: 0Create CA?
@Hand Drawing Olmport Drawing
**Site Plan/Drawing attached.**
PaOP. 9 of 3
IMPROVEMENT PERMIT
Davie County Health Department CDP File Number: 157639 - 1
210 Hospital Street C5-00000064
P.O.Box 848 County File Number:
Mocksville NC 27028 Date:
Q Inch
Drawing Drawing Type: Improvement Permit Scale: , pBlock
QN/A ft.
liV iOd
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. ........ ._ ... . .... . ... .
....... .. ........-: 1... ,
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APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT&ATC
1 Davie County Environmental Health
P.O.Box 8.t8 IO Hospital Stctet
lllocksville,NC 27028
.(336)753-67801 Fax(336)753-1680
Application For. itc Evaluatinly nprovement Pcrtit Authorization To Construct(ATG) Both
Type of Application. flew vstcm Repair to Existing System Expansion/Modification of Existing System or facility
*•+GNPORTAN11•I THIS APPLICATION C.t;TOOT BE PROCESSED UNLESS ALL Of'TILE REQUIRED
INF OR:41r1TLON IS PROVIDED.Rcfcr to the INfORMA110N BULLETIN for instructions.
APPLICANT INFORMATION
Namet.�> - N Contact Person
Address�l,'D— '° " t{am P}toite ''S34G r��i"} `_e�s�'J
City/State/ZIP .1.0402lid r)Rs A _Business Phone
Email I,ti nit(AM
Nance on PetmiVATC if Dierenr than
Above .
Mailing Address City1StatelZip
PROPERTY INFORMATION *DateHouse?F;acili Corner Plan ed
NOTE: A survey plat or site plan must accompany this application. Included: Site Pla Plat(to scale)
(Permit is valid for G0 mon ith site plan,no expiration with complete plat.)
Owner's Name Phone
/Number (12
Owner's Address= r CityStat01 vckn L7 J*
zip. -• Glx
Address Cityt�Qt�txX?
Lot Size Tax PIN# i Gtf f, .5 L
Subdivision Narne(if applicable) SectionrLot#
Directions To Site:
S ecify Problem Occurring:
IF RESIDENCE FILL OUT THE BOX BELOW
10 Peo le #Bedrooms #Bathrooms Garden Tub/Whirlpool Yes o
Rasementt Yes Basement Plumbing' Yes n
IF NON-RESIDENCE FILL OUT THE BOX BELOW
Type of facilityllusincss Total Square Footage of Building #People
#.
Sinks #Commodes 9 Showers #Urinals
EstimatQ water Usage(gallons per day) (Attach documentation of similar facility water
consumption)
FOODSERVICE ONLY: #Seats
TM s stent requested: Conventions] Accepted Innovative Alternative Other
Water Su l Tti c: Countv,'Cit Waicr (New tiS'cil Existing Well Cutnmunity Well
Do you anticipate additions or expansions of the facility this system is intended to serve? Yes No
If yes.what tape"
This is to ccnifythat the information provided on this application is true and correct to die best of my knowkxlgc. I understand
that any pertn(s)or ATC(s)issued hereafter are subject to suspension or revocation if the site is altered,the intended use
changes,or if the information submitted in this application is falsified or changed 1 hereby grant right ofentry to the Authorized
Representative of the Davie County health Department to conduct accessary inspections to determine compliance with applicable
laws and rules. I undcrstarmd that responsible for the proper identification azul labeling of property lines and comers and
locating and flaggin".,r
or staking t c housefacility lata'on proposed well to ation and the location of any other amenities.
1-1 Site Revisit Charge
Sign given Yes No "" r � Dattr(s):—�sccturmt _
Revised x1100 ` Cline Noufi v3ate:
_ MIS:
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AS data Is provided as is wpriaut warranty or guarantee of any kind ettlter expressed or Implied tnctedirtg but net Iusttred to the knptleci - -
tW warranties of merchw1abitity or fitness for a particular use.AM users Of Davie County s GIS websbe shalt hold harmless the County of tr N
Davie,North Gamine,its Agents,consultants,contractors or employees from any and all claims or causes of&etion due to or arising out ai c� a ,1 A �]�i �n�f,t
the use or Inabitlty to use the Gt8 data provided by this website. [—ri nted:Au g GG} 20 14
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DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
` APPLICANT INFORMATION PROPERTY INFORMATION
Ewan, 16,j kd`
1
Water Supply: On-Site Well Community Public
I Evaluation By: Aug�r Boring t �G Pit q— Cut
k
FACTORS ( 1 2 v4tl 7
Landscape position I r.— L
Slope % I I l L (%+
HORIZON I DEPTH { d -
Texture group I 5 G L ( t_ I
Consistence I 5 5 ' - s M
Structure 5Ae 5 P 'CH 3
` Mineralogy ( t _ Sof
I HORIZON II DEPTH 14
j Texture group C G
Consistence { \1 05 S f l, 5 ,
v Y 5 r
Structure _&04 , 1144n1L :J t
i
Mineralogy } 1�• el-W J9 ?t�
i HORIZON III DEPTHi --7 V 1 — ff 4
Texture group L J j,_ 64—
Consistence
4—Consistence j N: ; r l* RF
Structure j C �' G' r 67e 1-k 6iQ
Mineralogy
I HORIZON IV DEPTH i
{ Texture groupI
Consistence I
Structure # I
I
Mineralogy ). E
J SOIL WETNESS 1 f
I RESTRICTIVE HORIZON 1 I
SAPROLITE { 1 U
! CLASSIFICATION I 5 S
LONG-TERM ACCEPTANCE RATE
i 1 �SITE CLASSIFICATION: f EVALUATION BY: (�
LONG-TERM ACCEPTANCE RATE: ' V75 OTHER(S)PRESENT:
1 1 REMARKS:
iLEGEND
I Landscape Position
R-Ridge S Shoulder L-Linear slope FS-Foot slope N-Nose slope,
CC-Concave slope CV-Fonvex slope T-Terrace FP-Flood plain H I-Head slope
Texture
S -Sand LS -Loamy sand I SL Sandy loam L-Loam SI-Silt
SICL-Silty clay loam SIL Silty loamCL-Clay loam SCL-Sandy clay loam
SC-Sandy clay SIC-Silty clay C-Clay
j !
CONSISTENCE,
I VFR-Very friable FR-Friable FI-Firm VFI-Very firm EFI-Extremely firm
NS -Non sticky SS-Slightly sticky S-Sticky VS-Very Sticky
NP-Non plastic SP-Slightly plastic P-Plastic VP-Very plastic 4
j
StructureI
SC-Single grain M-Massive CR-Crumb GR-Granular ABK-Angular blocky
SBK-Subangular blocky L-Platy PR-Prismatic
1 Mineralogy i
1:1,2:1,Mixed
i �
{ Notes
Horizon depth-In inches
I Depth of fill-In inches
Restrictive horizon-Thickness,and inches from land surface }
{ Saprolite-S(suitable),U(unsuitable) 1
j Soil wetness -Inches from land surface to free water or inches from land surface to soil colors with chroma 2 or less
I Classification-S(suitable),PS6rovisionally suitable),U(unsuitable)
TTA Tl T - -----
j 1
1