219 Morrison Rd (2) Davie County,NC Tax Parcel Report Monday,November 7, 2016
................................. .......................... ............................................ ................................... ................... ............................- ............................................. ...............................................................
WARNING: THIS IS NOT A SURVEY
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Parcel Information 7
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Parcel Number: K20000000702 Township: Calahaln
NCPIN Number: 5707436764 Municipality:
8301134 Census Tract:
Account Number: 37059-801
Listed Owner 1:--- -- - WELLS FARGO BANK NA Voting Precinct: SOUTH CALAHALN
Mailing Address 1: - .-. I MAC#X7801-013(FC) Planning Jurisdiction: Davie County
City: FORT MILL Zoning Class: DAVIE COUNTY R-A
State:
SC Zoning Overlay:
Zip Code: 29715 Voluntary Ag.District: No
Legal Description: LOT 2 1.18AC OFF RIDGE RDJONES D S/D Fire Response District: COUNTY LINE
Assessed Acreage: 1.17 Elementary School Zone: COOLEEMEE
Deed Date: 6/2014 Middle School Zone: SOUTH DAVIE
Deed Book I Page: 009590851 Soil Types: MsC,MsD
Plat Book: 0009 Flood Zone:
Plat Page: 285 Watershed Overlay: DAVIE COUNTY
Building Value: 89420.00 Outbuilding&Extra 0.00
Freatures Value:
Land Value: 13460.00 Total Market Value: 102880.00
Total Assessed Value: 102880.00
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 Davis County's GIS website shall hold harmless the
County of Davie,North Carolina,Its agents,consultants,contractors or employees from any and all claims or causes of action due to
161 NC or arising out of the use or Inability to use the GIS data provided by this website.
1
OPERATION PERMIT or fice use DER
Davie County Health Department *CDP File Number 120377-2
210 Hospital Street K2000000702-wen
P.O. Box 848 County ID Number.
Mocksville NC 27028 Evaluated For. NEW
Phone:336-753-6780 Fax:336-753.1680 Township:
F'�A'd
plicant: Charles F. Harris Property Owner. Wells Fargo
dress: 1400 Finley Ave. Address:
City: N. Wilkesboro City:
State/Zip: NC 28659 State2ip:
_Phone#: (336)359-8500 Phone#:
PropeLty Location & Site Information
Address/Road#: Subdivision: Phase: Lot: .
219 Morrison Road
Mocksville NC 27028 Directions
structure SINGLE FAMILY Hwy 64 W, left onto Ridge, off of Ridge Road
#of Bedrooms: 3
#of People:
*Water Supply: EXISTING WELL
- 'IP Issued by.---
*System Classification/Description:
TYPE III B.SYSTEM W/SINGLE EFFLUENT PUMP -
*CA issued by: 2140.Nations,Robert
_ -- SaproliteSystem? OYes pNo
Design Flow: 3 -6 0 PUMP TO GRAVITY Pump Required?
- *Distribution Type:
eYes QNo
Soil Application Rate: 0 a 5 *Pre Treatment:
Drain field
r
cation Field 1 4 4 0 Sq• 8• *System Type: INFILTRATOR QUICK 4 STANDARD
rain Lines 2 Installer: Rusty Miller
Total Trench Length: 2 4 0 ft. Certification#: 1129
Trench Spacing: _ 9 Inches O.C.
Feet O.C. 'EH S: 2140•Nations,Robert
Trench Width: _ 3 Oinches
(*)Feet Date: 0 5 / 2 6 / 2 0 1 6
Aggregate Depth: inches
Minimum Trench Depth: 3 6 Inches
Minimum Soil Cover. a 4 Inches Approval Status
Maximum Trench Depth: 3 6 ® Approved C7 Disapprovetl
Inches
Maximum Soil Cover. a 4
Inches
CDP File Number 120377 -2 Septic Tank County ID Number: K2000000702-well
('Manufacturer Shoaf Lat,
Long:
STB: 760 -
Gallons:
1000 Installer: Rusty Miner
Certification 4; 1129
Date: 0 a / 1 1 / a 0 1 6
*EH S: 2140•Nations,Robert
*Filter Brand: POLYLOK PL-122 With Pipe Adapter
ST Marker. ❑ Yes � No Date: 0 5 / a 6 / a 0 1 6
Reinforced Tank: ❑ Yes ® NO Approval Status
1 Piece Tank; ❑ Yes [� No _®.Approved❑ Disapproved
Pump Tank
Manufacturer. Shoaf Installer Rusty Miller
PT: 42 Certification#: 1129
Gallons: 1250 *EH S: 2140-Nations.Robert
Date: 0 1 1 0 8 -/ 2 0 1 6 Date: 0 5 / 2 6 / 2 0 1 6
RiserSealed M Yes ❑ No
Riser Height: M Yes ❑ NO {Min.6 in.} = A ravat Status
pP
Reinforced Tank: ❑ Yes ® No `
Approved❑,Disapproved ;
1 Piece Tank: ® Yes ❑__.NO - � � = �� - �
Supply Line
Pipe Size: 2 inch diameter Installer: Randy Miller
Pipe Length: 5 5 feet Certification#: 1128
*Schedule: 40
*EH S: 2140-Nations,Robert
Pressure Rated ® Yes ❑ No Date: 0 5 / a 6 / a 0 1 6
Approved fittings ® Yes ❑ NO ApprovatStatus
D Approvetl❑ Disapproved
U e
Pump Type: zoeler Installer: Randy Miner
Dosing Volume: — Gal Certification#: 1128
Draw Down: Inches *EH S: 2140-Nations,Robert
*Chain: STAINLESS Date: 0 5 / a 6 I a 0 1 6
Valves Accessible p Yes ❑ NO
Flow Adjustment Valve O Yes ❑ No
Check-valve p Yes ❑ No Approval Status
PVC Unions Q Yes ❑ No C1 .Approved❑ Disapproved
Vent Hole Q Yes ❑ No
Anti-siphon Hole ❑ Yes ❑ NO
OPERATION PERMIT
q Davie County Health Department CDP File Number: 120377 - 2
210 Hospital Street K2000000702-We
P.O.sox Bas County File Number:
27028 Date:
s
Q Inch
Drawing Drawing T pe: Operation Permit Scale: QBlock
QN/A
I _ .__.
O
! 1 I LJ �.............. l
I t
i
CDP File Number 120377 -2K2000000702-Well
County ID Number:
Electric Equipment
NEMA X Box or Equivalent 2 Yes 0 N o Installer:
Box
A 47B Randy Miller
X 0'
Box 12 inches Above Grade ff] Yes El No 1128
c
Boxj., Certification#:
ox Adj.To Pump Tank f*I Yes El No
Conduit Sealed M* Yes 0 No 'EHS: 2140-Nations,Robert
Pump Manually Operable [E Yes 0 No Date: 0 5 / 2 6 2 0 1 6
*Activation Method:PIGGYBACK
-Approval Status 6 . ....
Alarm Audible (E Yes El NoDisapproved4:
E1-,,.,A6prov&d0 p
(E*
Alarm VisibleYes ❑ No
2140-Nations.Robert
*Operation Permit completed by;
-State A"nt' 0 5 2 6 2 0 1 6
# - - - --- — Date of Issue.
�.uthorized
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_proper,ty is served by a TYPE III B.
sewage septic system.
.
Rule.1961 requires that a TypeTYPE III Bseptic system meet the following criteria:
Minimum-System-Review By The Local Health Department: SYRS.
Management Entity_* OWNER
Minimum System Inspection/Maintenance Frequency ByCertified Operator:
N/A
Reporting Frequency By Certified Operator: NIA
Rule.1961 requires that a Type IV and V septic systems designed fora home/business owner must maintain a valid contract
with a public management entitywkh a certified operatoror a private certified operator forthe life of the septic system.
Rule.1961 requires that Type VI septic systems designed fora homelbusiness owner must maintain a valid contract with a
public management entity with 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 entity 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 01mport Drawing
**Site Plan/Drawing attached.**
CONSTRUCTION For office use only
AUTHORIZATION *CDP File Number ;120377-2
Davie Count Health Department K2000000702-Well
Y P County ID Number:
` 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 1 1 / 1 3 a 0 1 9
Applicant: Charles F. Harris Property Owner: Wells Fargo
Address: 1400 Finley Ave. Address:
City: N.Wilkesboro City:
State/Zip: NC 28659 State/Zip:
Phone#: �336'359-8500 Phone#:
Property Location & Site Information
Address/Road#: Subdivision: Phase: Lot:
219 Morrison Road
Mocksville NC 27028 Directions
Structure: SINGLE FAMILY Hwy 64 W, left onto Ridge, off of Ridge Road
#of Bedrooms: 3
#of People:
*Water Supply: EXISTING WELL
System Specifications
Minimum Trench Depth: a 4
rDesign
ssification: Provisionally suitable Inches
Minimum Soil Cover:
System? OYes XNo 1 a Inches
ow: 3 6 Maximum Trench Depth: 3 6 Inches
Soil Application Rate: 0 . 22 Maximum Soil Cover: a 4 Inches
*System Classification/Description: *Distribution Type: PUMP TO GRAVITY
TYPE III B.SYSTEM W/SINGLE EFFLUENT PUMP
Septic Tank: 1 0 0 0
Gallons
*Proposed System: 25%REDUCTION 1-Piece: O Yes ®No
Pump Required: (&Yes O No O May Be Required
Nitrification Field 1 8 0 0
Sq.ft. Pump Tank: 1 0 0 0 Gallons
No. Drain Lines rJ 1-Piece: OYes ®No
Total Trench Length: 4 5 0GPM--vs-- ft. TDH
ft.
Trench Spacing: OInches O.C.
9 ®Feet O.C. Dosing Volume: Gallons
_
Trench Width: _ 3 Aggregate Depth: Olnches
®Feet Grease Trap: Gallons
inches Pre-Treatment: O NSF OTS-1 OTS-II
Septic Tank Installer Grade Level Required: O 1 011 0111 01V
Page 1 of 3
e
CDP File Number 120377 - 2 County ID Number: K2000000702-Well
❑ Open Pump System Sheet
Repair System Required:®Yes ONO O No, but has Available Space
Repair System
Trench Spacing: 9 Q Inches O.C.
*Site Classification: Provisionally Suitable — ®Feet O.C.
Trench Width: Inches
Design Flow: 3 6 0 — 3 Feet
Soil Application Rate: 0 Aggregate Depth: inches
Minimum Trench Depth: .2 4 Inches
*System Classification/Description:
TYPE III B.SYSTEM W/SINGLE EFFLUENT PUMP Minimum Soil Cover: 1
Inches
*Proposed System: 25%REDUCTION Maximum Trench Depth: 3 6 Inches
Sq
0 .ft, Maximum Soil Cover: 2 4 0
Nitrification Field 1 8 Inches
_
No. Drain Lines 5 *Distribution Type: PUMP TO GRAVITY
Total Trench Length: -4 5 0 ft Pump Required: OYes QNo QMay Be Required
Pre-Treatment: O NSF OTS-I OTS-II
*Site Modifications
No grading or construction activity is allowed in areas designated for system and repair without approval of Health Department. Rem
750
*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. Charadam
Remaining
2000
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 130A336(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(9)).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: 1 1 / 1 3 / a 0 1 4
000,
Authorized State Agent: Malfunction Log Oyes
(0 Hand Drawing O Import Drawing
**Site Plan/Drawing attached.**
Page 2 of 3
CONSTRUCTION AUTHORIZATION
Davie County Health Department CDP File Number: 120377 - 2
210 Hospital Street K2000000702-Well
P.O.Box 848 County File Number:
Mocksville NC 27028 Date: 11 / 13 / .2014
0 Inch
Drawing Drawing Type: Construction Authorization Scale: . O Block
O N/A
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Page 3 of 3
P1 P2
Application For: J Site Evaluation/Improvement Permit ❑ Authorization To Construct(ATC) ❑ Both
.� Tyr�,of Application: ❑New System ❑Repair to Existing System O Expansion/Modification of Existing Systep r Facility
***IMPORTANT***THIS APPLICATION CANNOTBE PROCESSED UNLESS ALL OF THE RE ,/7
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
APPLICANT INFORMATION
Name to be Billed Contact Person Chig1.c5 irr ff t9>;O-r
Billing Address Home Phone 3��� OG
City/State/ZIP < O Business Phone 3Y6 11Y69 R-/,2 1)
Name on Permit/ATC if IYffferent than Above
Mailing Address City/State/Zip
PROPERTY INFORMATION *Date House/Facility Corners Fla ed
NOTE: A survey plat or site plan must accompany this application. Included: 0, Site Plan O Plat(to scale)
(Permit is valid for 60 months with site plan,no expiration with complete plat.)
Owner's Name 41 e O Phone Number
Owner's Address City/State/Zip
Property Address/ " !>1�1Z, 0 W City
Lot Size 5�SQ-0-0-_�F Tax PIN#,57D7-.-zy;i- (oS'�pU
SubdivisionRaame(if applicable) Section/Lot#
Directions To Site: r4Vh1 j3 nj W Q 4 D ST — t U M q 0 H 1,10ST-1-7-211, -,7--
itI)r 9-1 fox P kU P T � . � n,; a�► �
If the answer to any of the following' questions is"yes",supporting documentation must be attached.
Are there any existing wastewater systems on the site? Yes ONo
Does the site contain jurisdictional wetlands? ❑Yes Ao
Are there any easements or right-of-ways on the site? OYes)?No
Is the site subject to approval by another public agency? ❑YesXNO
Will wastewater other than domestic sewage be generated? OYes o
IF RESIDENCE FILL OUT THE BOX BELOW � ✓' (-�S
# People .#Bedrooms _ _ #Bathrooms _ Garden Tub/Whirlpool ❑Yes ;)Vo
Basement: ❑Yes o Basement Plumbing: ❑YesXNo
IF NON-RESIDENCE FILL OUT THE BOX BELOW
Type of Facility/Btisiness 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: # Spats
Type system requested: ❑Conventional ❑Accepted ❑Innovative ❑Alternative ❑Other
Water Supply Type: ❑ County/City Water ❑ New Well Xxisting Well ❑ Community Well
Do you anticipate additions or expansions of the facility this system is intended to serve? [i Yes )CNo { `;
If yes,what type? v
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 permit(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
loca oagging,o staking the house/facility location,proposed well location and the location of any other amenities.
Site Revisit Charge
Property owner's or owner's legal representative signature
Date(s):
Client Notification Date: 2b ��
' DA'VIE COUNTY HEALTH DEPAKI' 'NT ,
Environmental Health Section
Soil/Site Evaluation
APPLICANT INFORMATION PROPERTY INFORMATION
j Charles F. Harris } 219 Morrison Rd
336 359-8500 ; 55,000 Sq. Ft
f
j Water Supply: On- ite Well Community Lblic
j
Evaluation By: Augr Boring Pit ut
FACTORS f 1 2 3 j 5 6 7
Landscape position ( }
Slope%
HORIZON I DEPTH
Texture group }.
Consistence i }
Structure
MineralogyI
HORIZON H DEPTH I j
Texture groupr
Consistence
Structure '
MineralogyI
HORIZON III DEPTH
Texture group
Consistence f: {
Structure I I
Mineralogy ! j
HORIZON IV DEPTH
Texture group
Consistence !
Structure I
Mineralogy1. I
SOIL WETNESS ( }
RESTRICTIVE HORIZON I I
i SAPROLITE I
CLASSIFICATION I
LONG-TERM ACCEPTANCE RATE ( i
SITE CLASSIFICATION: EVALUATIQN BY: i
LONG-TERM ACCEPTANC RATE: OTHER(S) RESENT:
r
REMARKS:
LEGEND �I
Landscape Position
R-Ridge S-Shoulder ' L-Linear slope FS -Foot slope N-Nose slope,
CC-Concave slope CV- onvex slope T-Terrace FP-Flood plain H L Head slope
Texture
S Sand LS-Loamy san SL-Sandy loam L-Loam SI-Silt
SICL-Silty clay loam SII;,-Silty loam CL-Clay loam SCL-Sandy clay loam
SC-Sandy clay'- SIC-Sil clay C-Clay
CONSIS ,N . ,
Moist
VFR-Very friable FR-F *able FI Firm VFI-Very firm EFI-Extremely firm
3yel
NS -Non sticky SS-Slig�tly 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-Angar blocky j
SBK-Subangular blocky PL-Platy PR-Prismatic
i
Mineralogy.
1:1,2:1,Mixed
Notes f
Horizon depth-.In inches I
Depth of fill-In inches
Restrictive horizon-Thickness and inches from land surface
Saprolite-S(suitable),U(unsui,table)
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) _
3945
-- ( , - 320
ti /4 '67
.
N�
r�
`k
366 � c
t^ ^/1 Q ►y� aNV/t,
All data is provided as Is without warranty or guarantee of any kind eM1lkrF Os3eE 6r ImplleU Including but not limited to the implied
•\\' C warranties of merchantability orMcress for a particular use. All users of Davie County's DIS website shall hold harmless the County of DU N4
Davie,North Carolina,its agents,consultants,contractors or employees from any and all claims or causes of action due to or arising out Printed:Oct 16, 2014
5 of Ne use or inability to use the DIS data provided by this website.
I �
DAME COUNTY HEALTH DEPARTMENT
Environmental Health Section
P.O.Boa 848/210 Hospital Street
Mocksville,NC 27028
(336)751-8760
Account #: 990001257 Tax PIN/EH#: 5707-44-6560
Billed To: Matthew Jones Subdivision Info: Aq
Reference Name: Matthew Jones Location/Address: Morrison Road-27028
Proposed Facility: Residence Property Size: 6.845 Acres
ATC Number: 2481
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
**NOTE** This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental
Health Section prior to issuance of any building permit(s). This Form/Authorization Number should be presented to
the Davie County Building Inspections Office when applying for building permit(s)(in compliance with Article 11 of
G.S.Chapter 130A,Wastewater Systems, Section.1900 Sewage Treatment and Disposal Systems). THIS
AUTHORIZATION FOR WASTEWATER CONSTRUCTIO IS VVALID FOR A PERIOD OF FIVE YEARS.
Environmental Health Specialist's Signature: 61y. Date:
CERTIFICATE OF COMPLETION
**NOTE** The issuance of this Certificate of Completion shall indicate the system described on Improvement/Operation Permit
has been installed in compliance with Article 11 of G.S:Chapter 130A,Section.1900"Sewage Treatment and
Disposal Systems,"but shall in NO WAY be taken as a guarantee that the system will function satisfactorily for any
given period of time.
/oa
Septic System Installed By: `�6
Environmental Health Specialist's Signature: „ QQ� Date:
DCHD 05/99(Revised)
. .' -. DAVIE COUNTY HEALTH DEPARTMENT �a C)
° Environmental Health Section �d- -7
P.O.Boz 848/210 Hospital Street
Mocksville,NC 27028
(336)751-8760
IMPROVEMENT/OPERATION PERMIT
Account #: 990001257 Tax PIN/EH#: 5707-44-6560
Billed To: Matthew Jones Subdivision Info: a ka
Reference Name: Matthew Jones Location/Address: Morrison Road-27028
Proposed Facility: Residence Property Size: 6.845 Acres
** * bgr: 2481
N is mprovement/Operation Permit DOES NOT authorize the construction of a septic tank system or any wastewater
system. An AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION must be obtained from this
Department prior to the construction/installation of a system or the issuance of a building permit(in compliance with
Article 11 of G.S.Chapter 130A,Wastewater Systems, Section.1900 Sewage Treatment and Disposal Systems). THIS
PERMIT IS SUBJECT TO REVOCATION IF SITE PLANS OR THE INTENDED USE CHANGE. YOUR
WASTEWATER SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING SYSTEM.
Residential Specification: Building Type #People / #Bedrooms #Baths
Dishwasher: ❑ Garbage Disposal: ❑ Washing Machine: ❑ Basement w/Plumbing: ❑ Basement/No Plumbing: ❑
Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑
Lot Size fAC Type Water Supply_&� Design Wastewater Flow(GPD) Site: New Ef Repair❑
System Specifications: Tank Size GAL. Pump Tank GAL. Trench Width� Rock Depth/0a< Linear FtxC?W'
Other:
Required Site Modifications/Conditions:
IMPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER RISER(S)IF 6 K BELOW
FINISHED GRADE. ****NOTICE: Contact a representative of the Davie County Health Department for final inspection of this
system between 8:30 a.m.to 9:30 a.m.or 1:00 p.m.to 1:30 p.m.on the da of installation. Telephone#is(336)751-8760.****
. ,D
Environmental Health Specialist's Signature: Date: Z- - -
DCHD 05/99(Revised)
APPUCATION FOR SITE EVAUJATION/IMPROVEMENT PERMIT&A D
Davie County Health Department 2 7 �000
Eni ronmental Health Section JUN
P.O. Bou 848/210 Hospital Street
Mocksville, xc 27026 EWYI0 LTH
(336)751-8760 `
***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
1. Name to be Billed �// �ef�tJ Q7���j�S/ Contact Person cjyG�•� cJ/�n
Mailing Address ��� //' '/Q��<cf /CV Home Phone
City/state/ZIP y2rBus1ness Phone 41 �y
2. Name on Permit/ATC if Different than Above Q�n C /yC�/
Mailing Address City/State/Zip
3. Application For: ❑ Site Evaluation ❑ Improvement Permit/ATC "O-t,
4. System to service: ❑ House Wfiobile Home ❑ Business ❑ Industry ❑ Other
5. If Residence: # People # Bedrooms # Bathrooms
0 Dishwasher 0 Garbage Disposal washing Machine fl Basement/Plumbing H Basement/No Plumbing
6. If Business/Industry/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 01re11 ❑ Community
e. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑Yes ❑No
If yes,what type?
***IMPORTANT***CLIENTS MUSTCOMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED
BELOW. Either a PLAT orSITE PLAN MUST BESUBMITTED by the client with THIS APPLICATION.
Property Dimensions: <� WRITE DIRECTIONS(from Mocks le)to PROPERTyy
/l ( CG�i<G Gadd o
Tax Office PIN: # �� �Z y
Property Address: Road Name
City/zip/i iOWZ:�-v,,/1e 2
If in a Subdivision provide information,as follows: " ell&/b��
Name:
Section: Block: Lot: Date Property Flagged:
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
to conduct all testing procedures as necessary to determine the site suit ility.
� nn,,
DATE J O SIGNATURE Y/lAp
THIS AREA MAY BE USED FOR DRAWING YOUR SPIE PLAN(Include all o he following: Existing and proposed
property lines and dimensions, structures, setbacks, and septic locations).
Site Revisit Charge
Date(s):
Client Notification Date:
EHS:
Account No.
Revised DCHD(07/99) Invoice No. 7
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DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
APPLICANT INFORMATION PROPERTY INFORMATION
Account #: 990001257 Tax PIN/EH#: 5707-44-6560
Billed To: Matthew Jones Subdivision Info:
Reference Name: Matthew Jones Location/Address: Morrison Road-27028�
Proposed Facility: Residence Property Size: 6.845 Acres Date Evaluated: 7 v "f.4m
Water Supply: On-Site Well ✓ Community Public
Evaluation By: Auger Boring r/ Pit Cut
FACTORS 1 2 3 4 5 6 7
Landscape position L J_
Slope% Ab
HORIZON I DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH 8'' P-
Texture group
Consistence E
Structure
Mineralogy
HORIZON III DEPTH 19 V7
Texture group
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
j SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLrrE
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE r / n
SITE CLASSIFICATION: J eA e /U !t c% EVALUATION BY:
LONG-TERM ACCEPTANCE RATE: OTHER(S)PRESENT:
REMARKS:
LEGEND
LandscaW 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
Structur
SC-Single grain M -Massive CR-Crumb GR-Granular ABK-Angular blocky
SBK-Subangular blocky PL-Platy PR-Prismatic
MineraloYy
1:I, 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-gaUday/ft2
DCHD 05/99(Revised)
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