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Beauchamp Rd Lot 4 APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC Davie County Environmental Health P.O.Box 848/210 Hospital Street Mocksville,NC 27028. (336)751-8760/Fax(336)751-8786 Application For:AS ite Evaluation/Improvement Permit 0 Authorization To Construct(ATC) ❑ Both Type of Application: ❑New System ❑Repair to Existing System ❑Expansion/Modification of Existing System or Facility ***IMPORTANT***THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. APPLICANT INFORMATION t'A✓ke Y Nameto be Billed I n �l`�' ' `t" fj C=' 11''`` ontact Person Ql� Gu"' Billing Address 4 1-90 LC_ Je Home Phone O — /S S City/State/ZIP OLI t,I C ?,70,0 Business Phone 74 Name on Permit/ATC if Different than Above Mailing Address City/State/Zip KA 1 PROPERTY INFORMATION *Date House/Facility Corners Flagged NOTE: A survey plat or site plan must accompany this application. Included: ❑ Site Plan /Plat(to scale) (Permit is valid for 60 rrionths with site plan,no expiration with complete plat.) 9W-/S-6 4 Owners Name Molcle-1 Aldn Phone�ju;nber Owner's Address City/State/Zip VQ.tt 111 2x70 ,6 Property Address City Lot Size Tax PIN# Subdivision Name(if applicable) G /2 Section[Lot# / Directions To Site: i- re4U Q v h i"'/ If the answer to any of the following questions is"yes",supporting documentation mus_t be attached. Are there any existing wastewater systems on the site? ❑Yes VNo Does the site contain jurisdictional wetlands? ❑Yes/No Are there any easements or right-of-ways on the site? ❑Yes UlNo Is the site subject to approval by another public agency? ❑Yes ZNo Will wastewater other than domestic sewage be generated? Oyes, No IF RESIDENCIE FILL OUT THE BOX BFkOW #People #Bedrooms #Bathrooms . Garden Tub/Whirlpool ❑Yes 0 �,. Basement: Vles ❑No Basement Plumbing: ❑Yes ❑No IF NON-RESIDENCE FILL OUT THE BOX BELOW Type of Facility/Business Total Square Footage of Building #People #Sinks #Commodes #Showers #Urinals Estimated Water Usage (gallons per day) (Attach documentation of similar facility water consumption) FOODSERVICE ONLY: #Seats Type system requested: ❑Conventional ❑Accepted ❑Innovative. ❑Alternative ❑Other Water Supply Type: ❑ County/City Water ❑ New Well ❑Existing Well ❑ Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes ❑No If yes,what type? This is to certify that the information provided on this application is true and correct to the best of my knowledge. I understand that any perniit(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. I hereby grant right of entry to the Authorized Representative of the Davie County Health Department to conduct necessary inspections to determine compliance with applicable laws and rules. I understand that I am responsible for the proper identification and labeling of property lines and corners and locating and flagging or stakin a house/f�a�cility to ion,proposed well location and the location of any other amenities. u/ Site Revisit Charge Property owner's or owner's legal representative si ture Date(s): q�lv,or Client Notification Date: Date EHS: Sign given []Yes ❑No Account# Revised 11/06 Invoice# ` DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLItAWtIll+$:F(9RW Q6IflV Tax PIN/EH M 587DNFOIZMATION Billed To: Distinctive Properties of Triad Subdivision Info: Mock/Alan Lot#4 Reference Name: Location/Address: Beauchamp Rd-27006 Proposed Facility:. Residence Property Size: 2.388 Acres Date Evaluated: Water Supply: On-Site Well Community Public Evaluation By: Auger Boring Pit V Cut FACTORS 124 3 4 5 6 7 Landscape position L. Slope % HORIZON I DEPTH gyp.—LAS --2 Texture groupG G Consistence Structure }� IC• Mineralogy S&V. HORIZON II DEPTH Z — c) , Texture groupLC, Consistence Structure Mineralogy HORIZON III DEPTH Texture group Consistence Structure p Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: EVALUATION BY:�:Rr4e,-, LONG-TERM ACCEPTANCE RATE: OTHERS)PRESEUR REMARKS: C� i�`N C�2Jlr-�l y c =�6-Ay­ -8 L?Y�, . Landscape Position LEGEND';- 2 S yuvi f t A;5 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 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 Mineralo= 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 ter-urs nvnk "D-4—AN Davie County Environmental Health P.O.Box 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760/Fax(336)751-8786 IMPROVEMENT PERMIT Account #: 990005064 Tax PIN/EH#: 5870-65-2977.04 Billed To: Distinctive Properties of Triad Subdivision Info: Mock/Alan Lot#4 Address: 130 Oakhill Road Location/Address: Beauchamp Rd-27006 City: Advance Property Size: 2.388 Acres Reference Name: Proposed Facility: Residence **NOTE**This Improvement Permit DOES NOT authorize the construction of a wastewater system. An Authorization To Construct a wastewater system must be obtained from this office prior to the construction/installation of a wastewater system or the issuance of a building permit(in compliance with Article 11 of G.S.Chapter 130A,Wastewater Systems). This Improvement Permit is subject to revocation if site plans,plat or the intended use change. Permit Type: Aew ❑Repair ❑Expansion Permit Valid for: SKYears AoExpiration Residential Specifications: #Bedrooms Ll #Bathrooms#People "T Basement❑ Basement plumbing Non-Residential Specifications: Facility Type #People # Seats Square Footage(or Dimensions of Facility) Design Flow(GPD): 00 Type of Water Supply: R6ounty/City ❑Well ❑CommunityWell Site Modifications/Permit Conditions: AS s aaleu"I rsIv �• s Q -Iso be uS�Q System Typq J I LTAR Initial C4�—P , Repair . 'y Site Plan 9 p c1 LL U �i�c� y J Environmental Health Specialist O!aate ? - j i.p.11-06