251 Marchmont Dr Lot 4 (I� APPLICATION FOR SITE EVALUATIONAMPROVEMENT PERMI & ATC
f Davie County Health Department
Environmental Health Section , Y
P.O. Box 848 ?, �J� --. /3','
Mocksville, NC 27028 v`
i (704) 634-8760
****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL
THE REQUIRED INFORMATION IS PROVIDED.
1. Name to be Billed �Ld Contact Person l� C � VV-51,7
Mailing Address /�3 R Home Phone 9 q
City/State/Zip Business Phone 910 76 0 M3 1
2. Name on Permit/ATC if Different than Above
Mailing Address City/State/Zip
3. Application For: bq Site Evaluation [ ]Improvement Permit&ATC [ ]Both
4. System to Serve: ,House [ ]Mobile Home [ ]Business [ ]Industry [ ] Other
5. If Residence: #People_L___ #Bedrooms #Bathrooms-q- [ ishwasher[ I'Varbage Disposal
LJ'Washing Machine [ asement/Plumbing [ ]Basement/No Plumbing
6. If Business/Other: Specify type #People #Sinks #Commodes
#Showers #Urinals #Water Coolers
If Foodservice:#Seats Estimated Water Usage(gallons per day)
7. Type of water supply: [ County/City [ ]Well [ ]Community
8. Do you anticipate additions or expansions of the facility this system is intended to serve?[ ]Yes [eNo
If yes,what type?
EITHER A PLAT OR SITE PLAN
PROPERTY INFORMATION REQUIRED:***IMPORTANT***XA?U=OF THE PROPERTY MUST BE
^� 6--9 '( trcel q4
SUBMITTED WITH APPLICATION.
Property Dimensions: �J� ��e47e. WRITE DIRECTIONS(fr i ocksville)TO PROPERTY:
Tax Office PIN: #�-�- ; t ?01 S
Property Address: Road Name C \tR . ; on, Le �► �S
City/Zip ;
If4indivision rovi nformation,as fo lows:P , Go
N l
Section: Lot#: t S
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
Re rie tative[ of the Davie County
Health Department to enter upon above described property located in Davie County and owned
by �� �� \ to c " duct a testitcedu=resasnecessary to determine the site suitability.
DATE I SIGNATURE L
Revised DCH (06-96
THIS AREA MAY $E USED FOR DRAIVING YOUR SITE PLAN:
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7 s x(17, 6 �°�� , 215 00 a.
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a
PHOTOGRAPHY BY F - 8 F - 9 N
ALSTER & ASSOCIATES, INC.
COLUMBIA, SOUTH CAROLINA G 8 G - 9
DATE OF PHOTOGRAPHY: MARCH 28, 1976 H - 8 H - 9
• DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section SECTION LOT
Soil/Site Evaluation
APPLICANT'S NAME—� ��'C1i O 10 DATE EVALUATED
PROPOSED FACILITY PROPERTY SIZE ��•��
SUBDIVISION ,2A,0& �r. � i�. /� i7i�iTtO✓✓` ROAD NAMECY
C /'DSrGsifirllf
Water Supply: On-Site Well Community Public L�
Evaluation By: Auger Boring i"-, Pit Cut
FACTORS 1 2 3 4 5 6 7
Landscape position
Slope%
HORIZON I DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH (o r
Texture groupC G
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: EVALUATION BY: _ 6
LONG-TERM ACCEPTANCE RATE: OTHER(S)PRESENT:
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 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
DCHD(01.90)
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' Davie County Health Department
and Home Health Agency
Environmenta(Health Section
P.O.Box 848/ 210 HOSPITAL STREET
COURIER#09-4.06
MOCKSVILLE,N.C.27028
PHONE:(704)634-8760
August 6, 1997
David A. 'Macaione
1348 Westgate Ctr. Dr.
Winston-Salem, NC 27103
Re:. Site Evaluation/240 Crosswinds Dr.
Marchmont Acres/Lot 4
TAX PIN: 45880-91-8106
I .
1
Dear Mr. Macaione:
As requested, a representative from this office visited the
aforementioned site on July 28, 1997. Based upon the information �.
provided on the application for si(O 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.
1
If you have any questions, please feel free to contact this office.
'j
i
1 I Sincerely,
Robert B. Hall, Jr., R.S.
a Environmental Health Specialist
A
RH/wd
Enclosure(s)
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