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400 Livingston Rd (2)IV Ofl 'kAPPLICATIO FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC C Davie County Health Department a Environmental Health Section o t� PJ P. O. Box 848 V 1 Mocksville, NC 27028 �R ((336)751-8760 ****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSEUNLCO�v1EC0Ut Ham, ALL THE REQUIRED INFORMATION IS PROV 1. Name to be Billed jF•i t -w LE -rem c>,) c,+ & Mailing Address b1 1kmo j". Lk), City/State/Zip ��i �S TC�►V �S/� LL�/f? �� ,� 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: W Site Evaluation ❑ House W -Mobile Home # People 2— ❑ Garbage Disposal Specify type _ # Showers # Seats 7. Type of water supply: City/State/Zip Contact Person F f `TA4 Home Phone z4f�� Business Phone (Y—Improvement Permit & ATC ❑ Business ❑ Industry , ❑ Other # Bedrooms .2—_ Cil/Washing Machine ❑ Basement/Plumbing # People # Urinals Estimated Water Usage (gallonsperday) ❑ County/City Gi' Well Z Both # Bathrooms ❑ Basement/No Plumbing # Sinks # Water Coolers ❑ Community 8. Do you anticipate additions or expansions of the facility this system is intended to serve? `Yes ❑ No d If yes, what type? t L IlliK A MAI UR JL It PLAN PROPERTY INFORMATION REQUIRED: *** IMPORTANT *** A F THE PROPERTY MUST BE ll , J SUBMITTED WITH THIS APPLICATION. Property Dimensions: l:t.. ar 77 �% 1 WRITE DIRECTIONS (from �� 1 Mocksville) TO PROPERTY: Tax Office PIN: # ��_�� - � - 1 � 1 � � Property Address: Road Name 40/ 41At 9AIC357DAJ dio ; 5 City/Zip bukW&72J4 .2 %004 1 1 1 If in Subdivision provide information, as follows: i / 112,410 -67 -id Name: 1 1 1 Section: 1 1 � / 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 conduct all testing procedures as necessary to determine the site suitability. DATE �// SIGNATURE Revised DCHD (06-96) YOU MAY USE THE $ACK OF THIS FORM FOR DRAWING YOUR SITE PLAN. V� pN 4a Y. x�.�y�- " .09 \ +' u .0 r ...M'• i• 964' •�L .lf'OCS Ek,•.. _ ll` io „•'iia'"" ► a .40 Woo . •�� i -7"- •a.- - - f7 - - ted'/ s. ... ? Y' •�� J ti i '�"�: 't+ hep * .. •.:. ,r�,,bro ' +•� ::,"�`� s ,. ./ cq Ju •, DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section SECTION Soil/Site Evaluation APPLICANT'S NAME 621,C-4 PROPOSED FACILITY V_Z!5 SUBDIVISION Water Supply: On -Site Well Community Evaluation By: Auger Boring l/ Pit LOT DATE EVALUATED 7� PROPERTY SIZE ROAD NAME _ C i � p� -75 Public Cut FACTORS 1 2 3 4 5 6 7 Landscape position S Sloe % HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH 1J Texture groupG' Consistence 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:_ US LONG-TERM ACCEPTANCE RATE: !� REMARKS: DCHD (O1-90) EVALUATION 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 Health Department ' and Home Health Agency 98 �a�en$ER' Environmenta[Health Section NEv"d QHpN RGN 22� 1g P.O. Box 848 / 210 HOSPITAL STREET COURIER E�fEG�109-40-06 33 75 ,a�60 MOOKSVIL E#N.C. 028 PHONE: (704) 634-8760 April 30, 1998 Kenneth L. Brown 1701 Princeton St. Winston—Salem, PJC 27103 Re: 2 Site Evaluations Livingston Road/6.274 Acres Tax PIN: #5851-64-3332 Dear Client(s): As requested through your application(s), Robert B. Hall, Jr., R.S., Environmental Health Specialist(s) with this office, visited the aforementioned site(_.) on April 28, 1998. The purpose of said evaluation(s) was to determine the soil/site suitability for the installation of an on—site sewage system on each site. Based upon the information provided on the application(s) for site evaluation(s) and after the evaluation(s) was/were completed, the first site with the utility easement was found to be provisionally suitable for the installation of a modified, oversized on—site sewage disposal system. The result(s) of the evaluation(s) of the second site wi.h the lake, a copy of which is attached, indicate(s) that the site is unsuitable for the installation of an on—site sewage system for the following reason(s): Rule .1940 (e) — Topography .1941 (3) (b) — Soil Characteristics .1942 (a) — Soil Wetness Conditions .1943 (b) — Soil Depth .1944 (a) — Restrictive Horizons Due to the limitation(s) on the second site, this office is not aware of any modifications or alternative measures that can be implemented at the present time to upgrade the classification from "unsuitable" to "provisionally suitable." Your application for an improvement Permit for the second site must, therefore, be denied. Gage 2 Kenneth L. Brown April 30. 1998 You have the right to an informal review of this decision by the Environmental Health Director of this office and also by the regional staff of the Department of Environment, Health, and Natural Resources. You should contact this office to arrange for this further review. You may also wish to obtain the services of a private consultant to collect site—specific data and submit such data and a system design to this office for technical review. A site may be reclassified to provisionally suitable providec written documentation, including engineering, hydrogeologic, geologic or soil studies indicates to this office that a proposed on—site sewage system or a proposed alternative system can reasonably be expected to function satisfactorily. The substantiating data from these studies must indicate that: A. The effluent (wastewater) will receive adequate treatment; B. The effluent (wastewater) will not contaminate any ground water or surface water; and C. The effluent (wastewater) will not be exposed on the ground surface or be discharged to surface waters where it could cone into contact with people, animals or vectors. Finally, you have the right to a formal appeal of this decision if you file a petition for a contested case hearing with the Office of Administrative Hearings, P. 0. Drawer 27447, Raleigh, N.C. '27611-7447. A copy of a petition form can be provided to you upon request. The petition must be received by the Office of Administrative Hearings within thirty (37) days of the date of this notice. The hearing may be held in Davie County. If you file a petition for a hearing, you must send a copy of the petition to Mr. Richard Whisnant, DEHNR, Office of General Council, P. 0. Box 27687, Raleigh, N.C. 27611-7687. Please call or write this office if you have any questions or need any additional assistance. Telephone number: 336/751-3760 Address: Davie County Health Department Environmental Health Section P. 0. Box 848 Mock s v i l l e, N.C. 2'7028 Sin rely, Ae'4w - . Z-6 z /0. Robert B. Hall, Jr., R. S. Environmental Health Section RH/wd Enclosure(s): Soil—Site Report Billing Statement