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1715 Peoples Creek Rd Lot 2 — 1 11 l5 Lel 0 i APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PER I JUN — 619% Davie County Health Department Environmental Health Section P. O. Box 665 ENVIRONMEWAL HEALTH Mocksville, NC 27028 DAVIE COUNTY 1. Application/Permit Requested By Mailing Address O Home Phone d7 i S Business Ph O ZZ Z 2. Name on Permit if Different than Above 3. Application for: neral Evaluationtic Tank Installation Permit 4. System to Serve: ouse ❑ Mobile Home ❑ Place of Public Assembly ❑ Business ❑ Industry El Other ❑ Unknown 5. If house, mobile home:Subdivision � Section Lot #_2_ asement/Plumbing No. of People 7i ❑ Zhirg ent/No Plumbing No. of Bedrooms ? Machine No. of Bathrooms Z �� ishwasher Dwelling Dimensions Cl Garbage Disposal 6. If business, industry, place of public assembly, her: Specify type No. of People Served No. of Sinks No. of Commodes No. of Urinals No. of Lavatories No. of Water Coolers No. of Showers Water Usage Figures 7. Type of water supply: PPuc ❑ Private ❑ Community /bli 8. Property Dimensions / / , A49 Sewage Disposal Contractor 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes If yes, what type? '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: 41 OV Z.4 This is to certify that the information provided is correct to the best of my knowledge, and I understand I am responsible for all charges incurred from this application. DATE SIGNATURE CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBE ROPERTY MUST CHECK ONE: ❑ 1. 1 OWN the property. 2. 1 DO NOT OWN the property. If you checked Box#2, the rest of this form MUST be completed by the owner or a person authorized by the owner: I hereby give consent to the authorized representative of the Davie ounly Health Department to enter upon above described property located in Davie County and owned by a0 c: /p G & W, ' to conduct all testing procedures as necessary to etermine said site's s iu tability for a ground absorption sewage treatment and disposal syspm. 0 -� 5 s' DATE SIGNATURE DCHD(193) pv 'Sv �•r V7, t6 • 1 � AC+ PIPES C.. &S S.S �24{.r G).G$w • $o�Bl DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation Q NAME X1.7- f' , S DATE EVALUATED - `S ADDRESS PROPERTY SIZE ( 9A p PROPOSED FACIILTY ,Ad V aQ LOCATION OF SITE Q� \J� Water Supply: On-Site Well _ Community Public Evaluation By:(�'V—Auger Boring Pit Cut FACTORS 1 1 2 3 4 Landscape position Sloe z Ci_ )!;0 SsS . f V. ,�F- HORIZON I DEPTH ID, 1, TT_ - 12 Texture group 5' C C t Consistence V T Structure Mineralogy HORIZON II DEPTH W •4 Texture grouC Consistence i • - T Structure L Mineralogy HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS S S -5.S RESTRICTIVE HORIZON -- SAPROLITE -- CLASSIFICATION 4S •S S LONG-TERM ACCEPTANCE RATE g- SITE CLASSIFICATION: Q• EVALUATED BY: C lIrwl� LONG-TERM ACCEPTANCE RATE: •� OTHER(S) PRESET T: ON S 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 :lay loam- SIL-Silty loam CL-Clay loam SCL-Sandy clay loam SC-Sandy clay SIC-Silty clay C-Clay CONSISTENCE Moist VFR-V?---y 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 .3C-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 DCHD(01-901 ■■■■/■■■■■■■■■■■■■■■■■■■■■■ ■/■E■/■N■/■MOMNONM■ ■■■'■■■■■ ■■M■MM■■ ■■■■/■■■■■■■/'■'■■■■■■■■■■■■/■■■■■■■'■■■■■■/" "MMM■H EMOMMMEM■ mommoll ■■N'MMM■■■M■■eM■M■"■M/■■■■■MM■'Me'■'■■■ ■■■ MEMEMMEME■■EMMEN on ■■■■"■■■■■"'■■'■■■■■■■■■■■■'■■■■■■'■'■■■■■'■OM■ ■M■MEM■■■■■■ONE■ ■■■'■■■■■■■■■■■■■■■■■/■■■'■■■■■ '■■■"MN■■'■■■'■■■■■'/■■"MONO■ ■'■■■'■■■MMMM'MNNMM■'MMM■MMMMMMMMN■"■■■■■■'■■■■�'=■MM■■MMM■■■■■■■■ iiiiiiiiiiiiiiiiiiiiii■u■liiiiiiiiii i�i■iiii=i/iu■■iiiii=i iiiii ......................■■.'................■...'■'S"NEEM'.'■■■_■.■ .......■■.......................�.......■■�'N■■MOO■■■■■■■■■■ MOM .........................■...... '.'■M'.. .. .................. .....................N■■//■S■■■■/■H■.....NONE No.■MMEMEM.■■mom SENSE 0 MEMO EMEMEM I� INN MEMMINEEMEMEM C: " ' : M:::MIwomm" :: i : EN. : : .■■■■■■O■MM■■■■■N■■O■■OMN■N'/O■H .� SSSS . . M■Mno NONE MMUMME �OMMEMN� MMMMMMMMMMMMMMMMM MEMO MUMM:CC::il: _: :�CC11 min _:N ■■■'■'■'■■'■■■■■'■■■■■'■■■MMM■'■■'■ ■■ N ■M■■ ■ ■■MOON■■■� ■■■■■N ■�\■■� ■M■�■..tea=:a:1M ■SEM Mini MMM, ■■M■ME iiiiiiiiM�=ii� iii►�iiiiuii�ieiiiiiM�e�ii:�i� , ■ iiiiiiiie:ii� ■■■■■■MMM■/�Ni�\■■■■MM■■■HM■Ml\Me�/■ No ■MMMMM■■ IN P-p- M No MESON No Old" ME MEMENIMM iiiiii,'�,ieiii:u■iii�i/i,�=i�:.•'.�M-:i'' '�I. :CC=iiiiil�� iiiiiiiiiiiiM■iiiiiiiiiM'iii,iii i�ii�` ' Mi■isi MMMMMMMMM■■■NOMMEN 0 ME SOMEONE MMMM'MMNMMo�MNMMMN■ ■M MM■ ■M■M■M� Mom on INNER mom ■■■MON■HMMMM MMM��iMMMMMM■■ ■ ■ NMMM■'■MMMM ■■■OOHM ■■■M�MM[�.e.>�■MMNMMM� H■:ate■M�� :CC C:C: C ":::: : : :::::::�:C .e SSSS Z"■ . MMEEM::..=::�_:::: M no ■ :..■naE ■'■■■■■EON■■'/N■■■■■ONNNM'NM■N■ ■NN mo 0■O■H■SEEM SH■ OMEN MOMMORNME ■■■■u■■■■■■■■■■■■■■■■■■■■■■■■■■�i■=�=■ ■ ■ ■NNiiiii■■iii MENEM ME ISIMEMMEN MMEN MOMMM OEM ME MONIES! MEMERE �mmwwmmmmmm . MEMOMMNMMEMME■ ■■ ■M' ■' .....■MNMM■M■'■■ MESO' FREAMOMMEMME�M■ME■■MMOMMI�M ■■�■MN■■ MNMMONHMENOMONE■ 0 ■■■NMMNM■MMM■■OONMM■■■M1l\IIMMOMMOM■■■MMNMMMMMM■MMMMHMMMM■MMM■■N■■ ,e„ ,,,,■,,,,,■,,,,,,,,,,■,,,■■�iii�■i■iiiiiii,■iiii�■iiiiiiiiii■i =I■■■■■ ■M■■■■■■■■■■■■■M/MN■■■■NMMNM■ ■ ■NM'■MMMMN■NMMM■NMN■NMN■ Davie County YkaltFr De artment and .dome Nealtk AyeflCy 210 HOSPITAL STREET/P.O. BOX 665 MoCKSVILLE.N.C. 27028 PHONE:(704)634-5985 June 14, 1995 Terry W. Falls 2310 Silas Creek Parkway Winston-Salem, HC 27103 Re: Site Evaluation March Ferry-Lot 2 Dear Kr. Falls: As requested, a representative from this office visited the aforementioned site on June 13, 1995. Based upon the information provided on the application for site evaluation and after the evaluation was completed, the site was found to be provisionally suitable for the installation of an on-site sewage disposal . system. If you have any questions, please feel free to contact this office. Sincerely, Charles E. Little, R.S. Environmental Health Section CL/wd Enclosure