276 Ijames Church Rd Lot 3 APPLICATION FOR SITE EVALUATIONAMPROVEMENTS PERMIT O V
Davie Ccunly Health Department I I
Environ uncal Health Section JUL
P. O. Box.635
Mocksville,NC 27028 ENVIRONMENTALi?r":,.TH
DAVIE COUfITY r
�y
1. Application/Permit Requested By.
Mailing Address
Horne Phone " q 9 F pj_7-1-713usiness Phone
2. Name on Permit if Different than Above
3. Appiication/Permit for: P--General Evaluation ❑ Septic Tank Installation
4. System to Servo: m ouse ❑ Mobile Home ❑ Place of Public Assembly
❑ Business ❑ Industry ❑ Other ❑ Unknown
o
� �.
5. If house, mobile home: Subdivision �1f' , - 1 i. - -- Section Lot #
❑ Basement/Plumbing
No. of People ❑ Basement/No Plumbing
No. of Bedrooms ❑ Washing Machine
No. of Bathrooms _ ❑ Dishwasher
Dwelling Dimensions , �- ��z��J ❑ Garbage Disposal
6. If business, industry, place of public assembly, other: 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: Public ❑ Private ❑ Community
8. Property Dimensions rVA 171 -tl Sewage Disposal Contractor
9. Do you anticipate addit
ions/expansion of the facility this sytem is intended to serve? V4es ❑ No
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:
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 V SIGNATURE i
CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY
MUST CHECK ONE: Ekli. I OWN the property. goeTn.e/l., ❑ 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 representativ of the Davie Cou Health Department to enter upon ab ve des ib
property located in Davie County and owned by
to conduct all testing procedures as necessary to d e mine said site's suitability f ground absorption wage treatment
and disposal system.
(J � ATE SIGNATURE
DCHD(12.90)
� of # 3
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
NAME ,�. ���N DATE EVALUATED
ADDRESS �ro,W, PROPERTY SIZE • �• o�� \\
PROPOSED FACIILTY d4. LOCATION OF SITE `1-�c1►��o �4
Water Supply: On-Site Well _ Community Public
Evaluation ByS:-tAuger Boring P41 Cut
FACTORS 1 2 3 4
Landscape position 5
Slope %
HORIZON I DEPTH
Texture groupL
Consistence
Structure
Mineralogy
HORIZON II DEPTH
Texture groupC
Consistence _Z
Structure
Mineralogy
HORIZON III DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS $ SS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE �
SITE CLASSIFICATION: ��- EVALUATED BY:
LANG-TERM ACCEPTANCE RATE: •� OTHER(S) PRESENT: tas
REMARKS: � `� �ts��^ \� �
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-Ve-y friable FR-Friable FI-Finn 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