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188 Ashley Brook Ln Lot 8 ` DAVIE COUNTY ENVIRONMENTAL HEALTH ' P.O.Box 848/210 Hospital Street P ` Mocksville,NC 27028 (336)753-6780/Fax#(336)753-1680 V!` AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION Account #: 990004483 Tax PIN,EH#: 5729-66-5406 Billed To: Jane Whitlock Subdivision Info: Richardson Estates Lot# Reference Name: Revised: 6/29/11 Location/Address: Ashley Brook Lane-27028 Proposed Facility: Residence Property Size: 125 195x125x Site Type: Ci ew ❑Repair ❑Expansion ATC Number: 4792 **NOTE**This Authorization to Construct(ATC)MUST BE ISSUED by the Davie County Environmental Health Section prior to issuance of any building permit(s),(in compliance with Article 11 of G.S.Chapter 130A Wastewater Systems, Section.1900 Sewage Treatment and Disposal Systems). THIS AUTHORIZATION TO CONSTRUCT IS VALID FOR A PERIOD OF FIVE YEARS. This ATC is subject to revocation if site plans,plat on the intended use change. Residential Specifications: #Bedrooms #Bathrooms #People_,,�L Basement❑ Basement plumbing❑ Non-Residential Specifications: Facility Type #People #Seats Square Footage(or Dimensions of Facility) ��' Lot Size Type of Water Supply: ❑County/City , �V{� ell ❑Community Well System Specifications: Design Wastewater Flow(GPD)�Tank Size '/ GAL.Pump Tank JXAL. Trench Width 36.` Max.Trench Depth 3Z Rock Depth Linear Ft.3 V7 Site Modifications/Conditions/Other: Contact the Davie County Environmental Health Section for final inspection of this,system between 8:30-9:30a.m:on the day of installation. Telephone# 336)751-8760. s� 'O ALL I It °° fi ,c (\ Environmental Health SpecialistZI DCHD.11/06(Revised) , 1 DAVIE COUNTY ENVIRONMENTAL HEALTH P.O.Box 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 Fax#(336)751`-8786 OPERATION PERMIT Account #: 990004483 Tax PIN/EH #: 5729-66-5406 Billed.To: Jane Whitlock Subdivision Info: Richardson Estates Lot#8 Reference Name: Location/Address: Ashley Brook Lane-27028 Proposed Facility: Residence Property Size: 125x195x125x ATC Number: 4792 **NOTE**The issuance of this Operation Permit shall indicate the system described on the ATC 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. CJ System Type: � S.T.Manufacturer 5 Tank Date Tank ize� Pump Tank Size System Installed Ey: 0 G E.H. Specialist: Date: 1 I I � , Col I 1} it ( I Cf^ �-- 1 o,4 1 DCHD 11/06 (Revised) APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC Davie County Environmental Health �✓E,V E P.O.Box 848/210 Hospital Street JUN 2 2011U Mocksville,NC 27028 p (336)753-6780/Fax(336)753-1680 Application Y. mprovement Permit ❑ Authoro on To Construct(ATC) ❑ Both Type of Application: ❑New System ❑Repair to Existing System L5Expansion/Modification of Existing System or Facility ***IMPORTANT*** THIS APPLICATION CANNOTBEPROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. APPLICANT INFORMATION Name �}�/1 e W h d l oe_k Contact Person Address nV0A 741 /Z� AitIP� Home Phone — City/State/ZIP A0SI V"Ille-' 77.10 9 Business Phone Name on Permit/ATC if Different 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: ❑ Site Plan ❑Plat(to scale) (Permit is valid for 60 months with site plan,no expiration with complete plat.) Owner's Name < 01 14 19- Phone Number Owner's Address City/State/Zip Property Address City Lot Size Tax PIN# - &6-W06 Subdivision Name(if applicable) I dA/Ala Section/Lot# b Directions To Site: S 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 4lo Does the site contain jurisdictional wetlands? _Yes /No Are there any easements or right-of-ways on the site? _Yes -No Is the site subject to approval by another public agency? _Yes -,No Will wastewater other than domestic sewage be generated? Yes /No IF RESIDENCE FILL OUT THE BOX BELOW FBa eople #Bedrooms #Bathrooms Garden Tub/Whirlpool ❑Yes ❑No sement: ❑Yes ❑No Basement Plumbing: ❑Yes ❑No IF NON-RESIDENCE FILL OUT THE BOX BELOW Type of Facility/Business 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: Seats Type system requested: e onventional ❑Accepted ❑Innovative ❑Alternative ❑Other Water Supply Type: ❑ County/City Water T' ew Well ❑Existing Well ❑ Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes ❑ No If yes,what type? 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 pen-nit(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 0<_RN rules. I understand that I am responsible for the proper identification and labeling of property lines and corners and 11ocatingland Yng11 0skithe u e/facility location,proposed well location and the location of any other amenities. Wo e owners or owner s lega rep sentative signature Site Revisit Charge 6)1 Date(s): t r2 Client Notification Date: Date EHS: Sign given OYes ❑No Account# Y Revised 11/06 Invoice# DAVIE COUNTY ENVIRONMENTAL HEALTH P.O.Box 848/210 Hospital Street Mocksville,NC 27028 �( (336)751-8760 Fax#(336)751--8786 ' U AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION Account #: 990004483 h Tax PIN/EH#: 5729-66-5406 Billed,To: Jane Whitlock Subdivision Info: Richardson Estates Lot#8 *ff Reference Name: Location/Address: Ashley Brook Lane-27028 Proposed Facility: Residence Property Size: 125x195x125x ATC Number: 4792 . Site Type: ❑New ❑Repair ❑Expansion **NOTE**This Authorization to Constrict(ATC)MUST BE ISSUED by the Davie County Environmental Health Section prior to issuance of any building permit(s),(in compliance with Article 11 of G.S. Chapter 130A Wastewater Systems, Section.1900 Sewage Treatment and Disposal Systems). THIS AUTHORIZATION TO CONSTRUCT IS VALID FOR A PERIOD OF FIVE YEARS. This ATC is subject to revocation if site plans,plat or the intended use change. Residential Specifications: #Bedrooms 0, #Bathrooms #People Basement❑ Basement plumbing❑ Non=Residential Specifications: Facility Type #People #Seats Square Footage(or Dimensions of Facility) Lot Size �� "� -� Type of Water Supply: (C�unty/City ❑Well ❑Community Well System Specifications: Design Wastewater Flow(GPDj2_q0 Tank Size/ GAL.Pump Tank AAL. Trench Width Max.Trench Depth 34, Rock Depth Linear Ft. As stated in 15A NCAC 18A.1969(5) p-P a.y�� J�-1 .y Site Modifications/Conditions/Other: accepted S�'ntsms May '!. :, PIP u Contact the Davie County Environmental Health Section for final inspection of this system between 8:30—9:30a.m.on the day of installation. Telephone#(336)751-8760. \ ' V 7 'k3 ,pc3lf ikeck 72 u n qy14 -- - Qfw Environmental Health Specialist Date: v DCHD 11/06(Revised) 1 pLIC JO SITE EVALUATION/IMPROVEMENT PERMIT & ATC `"� Davie County Environmental Health P.O.Box 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760/Fax(336)751-8786 A ion For: q Site Evaluation/Improvement Permit ❑'Authorization To Construct(ATC) 9 Both Type of Application: )(New System ❑Repair to Existing System ❑Expansion/Modification of Existing System or Facility ***IMPORTANT***THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. APPLICANT INFORMATION ( '+ ' Name to be Billed )h')4-1Dck- Contact Person cJ W Ytor k Billing Address Home Phone Cel/ City/State/ZIP p Business Phone >3 Name on Permit/ATC if Different than Above Mailing Address City/State/Zip PROPERTY INFORMATION *Date House/Facility Corners Flagged a b 7 NOTE: A survey plat or site plan must accompany this application. Included: DKSite Plan ❑Plat(to scale) (Permit is valid for 60 months with site plan,no expiration with complete plat.) Owner's Name Ja ne W h!fl 0 CIC Phone Number 33(o-9 ifO'7115 t{ Owner's Address 202L i6hk,4 8r6l)Jin e_ City/State/Zip aMCk6V1 J(e� IU- ,7D,2- Property Address City Lot Size 1 a 5 X x <j Tax PIN# Subdivision Name(if applicable) Q d nSection/Lot# B Directions To Site: CIALIbAl Jew bn h-',h) A (L L-n pay-nej pyo J; 5ce- Qlx}'�-OIC.)'1�c1 Y11A.n 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 KNo Does the site contain jurisdictional wetlands? ❑Yes Wo Are there any easements or right-of-ways on the site? ❑Yes BNo Is the site subject to approval by another public agency? ❑Yes CgNo Will wastewater othei than domestic sewage be generated? OYes.®.No IF RESIDENCE FILL OUT THE BOX BELOW #People _/ #Bedrooms 0— #Bathrooms Garden Tub/Whirlpool ❑Yes 1KNo Basement: ❑Yes �ZNo Basement Plumbing: ❑Yes 54No IF NON-RESIDENCE FILL OUT THE BOX BELOW Type of Facility/Business 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: #Seats Type system requested:. ,(Conventional ❑Accepted ❑Innovative ❑Alternative ❑Other Water Supply Type: ❑ County/City Water 3'New Well ❑Existing Well ❑ Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes ,KNo If yes,what type? 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 corers and locating and flagging or staking the hquse/facili–ty ocat' n,proposed well location and the location of any other amenities. el-�A- Site Revisit Charge Prope owner's or owner's legal.representative signature Date(s): Client Notification Date: Date EHS: Sign given []Yes ❑No Account# Revised 11/06 Invoice# � i GoMAPS - Davie County NC Public Access SKATER SagN D COUNTY_BOUNDARY t ,STREETS.. RAILROAD CENTERLINE PARCELS 01 CITY LIMITS a SERWJDA RUN 4COOLEEMEE LIAVIL'tXi{UTY oN tYCeR o Mt?C"SVILLE 1 y Tuesday,November 13 2007 l f $ � f 0 o312ft l Hca` ***WARNING:THIS IS NOT A SURVEY!*** This map is prepared for the inventory of real property found within this jurisdiction,and is compiled from recorded deeds,plats,and other public records and data.Users of this map are hereby notified that the aforementioned public primary information sources should be consulted for verification of the information contained on this map.The County and mapping company assume no legal responsibility for the information contained on this map. f r GoMAPS - Davie County NC Public Access WATER BS&gND COUNTY BOUNDARY 125 PARCEL DIMENSIONS a ADDRESS de DRIVES STREETS • w RAILROAD CENTERLINE ED PARCELS o CITY LIMITS El8E MUDA MM ElCOOLEEMEDAVIS COMY EJMOCKSVILLEv 0 202 , S HL 0 I t As Friday,November 23 2007 ***WARNING:THIS IS NOT A SURVEY!*** ` This map is prepared for the inventory of real property found within this jurisdiction,and is compiled from recorded I�h deeds,plats,and other public records and data.Users of this map are hereby notified that the aforementioned public primary information sources should be consulted for verification of the information contained on this map.The County and mapping company assume no legal responsibility for the information contained on this map. DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANTI O TI TT ,I'ItIOtPEIiJnY INFORMATION ccoun 3 Tax PIN/EH#: 57 - Billed To: Jane Whitlock Subdivision Info: Richardson Estates Lot#8 Reference Name: Location/Address: Ashley Brook Lane-27028 Proposed Facility: Residence Property Size: . 125x195x125x1 Date Evaluated: — - �{ } Water Supply: On-Site Well Community Public Evaluation By: Auger Boring i�'�f Pit Cut FACTORS 1 2 3 4 5 6 7 Landscape position L L_ Slope% HORIZON I DEPTH C+ - 1-1,5- Texture -1,Texture grou 5C P _ G Consistence �- Structure Mineralogy HORIZON H DEPTH 3- V4_ Texture rouConsistenceStructureMineralo HORIZON III DEPTH Texture group Consistence p ' Structure Mineralogyr HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE O. 7. 7 `- SITE CLASSIFICATION: EVALUATION BY: 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 Textures 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 C:QNSISTF,NCR Moist VFR-Very friable FR-Friable FI-Firm VFI-Very firm EFI-Extremely firm WKI 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 Mineraloav 1:1,2:1,Mixed 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,(1rovisionally suitable),U(unsuitable) LTAR-Long-term acceptance late-gal/day/ft2 DCHD 05/05 (Revised) ■■eeeeeee■ee■■■■e■■eeea■■■■■■■■■■■■■■■■■■■■■■■e■■ee■■■■■■e■ee■e■■■ ■■■/■■■■■/■■■■/■■■■s■e■■*�c■:ccs■r■■a■■■■■■■■■■■■■■■■/■■■■■■■■■/■■■ ■■/■■■■■■■■■■■■■■■/■■■t■■■1�'".1■e■ /%it■■■■■/■■■/■■■■//■■■■■■■■■■■■■ ■■■■■■■■■■■■/■■■■/■■■■Il■rice■/■■■■a��■■■■■■■■■■■e■■/■■■■■■■/■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■If;�t�■�■■■■■■■�:iii■/■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■t■■■■■■■■■■/■■■■■11/_/1■■■■t■■ ■■ill■■■■■■■■■■■■■■■■■■■■■■■■■/■■■ ■■/■■■■■■■/■■/■/////■■11/■///■■/■■/�■It/■■■■■■■■■■■■ee/e■■■■■■■■■■/■ ■/■/■■■■■■//■■ecce■■■■11■�ra�■■e■■■�:■11■■e■■e■■eeeee■■■e■■■■■■e■■■/■ ■■/■■/■■/■■■■/■■■■■■/■/■■■■■i�ii�w�ie9�!�IM9■eE'dE�IJJI�■mfr/C�ii1/■G'�e■cell/■ ■■//■■■■/■//■//////■C►!//®!9/�iG:isC."'1/ii�iiiii�/if1///ri■■■■■■■R�rJi�//%/■i/./I■■■ MENNENMENNEN MEEMEMmsmmomMEMNON MENNEN ■■■■/■////■/■///■■■■■■■■seee■■es/e■■/■■■e■■■e■ee■■■■■eee■■■■■■■■■■ ■■■■ee/■/■ecce■■■■■■e■eee■■e■■■■■■■■e■■■e■■■■■■e■■e■■ee■e■eeee■■■■ ■■■■■/■■/e■/e■■e■■ee■■■/■■e■ee■■eee■■e■/e■■■■//■///■/■//////■/■■■■ ■/■/■e■■/■■/■/■/■■ecce/■//■////■■■■/■////■■///■■■■■■///■■■■■■■/■/■ ■■■■■■■■■■■■/■■■■■■■■■■■■■■■■■■■Iii■■■■■■■/s/■■■■/■■■■/■■/■■■/■■■■■ Davie County Environmental Health P.O.Box 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760/Fax(336)751-8786 IMPROVEMENT PERMIT Account M 990004483 Tax PIN/EH#: 5729-66-5406 Billed To: Jane Whitlock Subdivision Info: Richardson Estates Lot#8 Address: 202 Ashley Brook Lane Location/Address: Ashley Brook Lane-27028 City: Mocksville Property Size: 125xl95xl25x Reference Name: Proposed Facility: Residence **NOTE**This Improvement Permit DOES NOT authorize the construction of a wastewater system. An Authorization To Construct a wastewater system must be obtained from this office prior to the construction/installation of a wastewater system or the issuance of a building permit(in compliance with Article 11 of G.S. Chapter 130A,Wastewater Systems). This Improvement Permit is subject to revocation if site plans,plat or the intended use change. Permit Type: (e4ew ❑Repair ❑Expansion Permit Valid for: Years ❑No Expiration Residential Specifications: #Bedrooms a- #Bathrooms #People Basement❑ Basement plumbing❑ Non-Residential Specifications: Facility Type #People #Seats Square Footage(or Dimensions of Facility) Design Flow(GPD): �Ly d Type of Water Supply: UCounty/Ci W ❑Community Well As stated in 15A NCAC 18 .1�69e(0 Site Modifications/Permit Conditions: accepted system. System Type LTAR Initiala,Jr Q 0r 7 Repair '7 S LA . V .fin:�•�2 J � � 5 Environmental Health Specialist Date i.o.l 1-06 Excise Tax:$-0- Recording Information Drafted by:Tamara A.Fleming,Attorney at Law,Ten Court Square,Mocksville,NC 27028 Mail to:Grantees @ 202 Ashley Brook Lane,Mocksville,NC 27028. Property Address: 188 Ashley Brook Lane,Mocksville,NC 27028 TAX MAP: H-3-4,Blk A,Pcl 13 WARRANTY DEED THIS DEED made this_day of August,2011,by and between JANE B.WHITLOCK (a free trader)(Grantor Address:202 Ashley Brook Lane,Mocksville,NC 27028);hereinafter referred to as the GRANTORS, to ASHLEY BROOK WHITLOCK (Grantee Address: 202 Ashley Brook Lane, Mocksville, NC 27028) and ALEX RANDALL GRUBB (Grantee Address: 130 Kent Lane,Mocksville,NC 27028); hereinafter referred to as the GRANTEES; WITNESSETH: THE GRANTORS,for valuable consideration paid by the GRANTEES,receipt of which is acknowledged, have and by these presents do convey unto the GRANTEES in fee simple, all that certain parcel of land situated (the "property") in Mocksville Township, Davie County, North Carolina, and more particularly described on attached"Exhibit A." TO HAVE AND TO HOLD the property and all privileges and appurtenances thereto belonging to the GRANTEES in fee simple. THE GRANTORS COVENANT with the GRANTEES,that the GRANTORS are seized of the property in fee simple,have the right to convey the property in fee simple,that title is marketable and free and clear of all encumbrances,and that the GRANTORS will warrant and defend the title against the lawful claims of all persons whomsoever except for the exceptions hereinafter stated. Title to the property is subject to the following exceptions: Easements and restrictions of record. All or a portion of the property herein conveyed includes or X does not include the primary residence of Grantor. The terms GRANTORS and GRANTEES as used herein include the masculine and the feminine,the singular and the plural,as the context requires,and the heirs,successors,and assigns of the parties hereto. IN WITNESS WHEREOF,the GRANTORS have hereunto set their hands and seals the day and year first above written. GRANTORS: (SEAL) Jane B. Whitlock NORTH CAROLINA COUNTY OF I,a Notary Public,of the aforesaid County,do hereby certify that Jane B.Whitlock,Grantor, personally appeared before me this day and acknowledged the due execution of the foregoing instrument for the purposes therein expressed. Witness my hand and Notarial stamp or seal,this_day of August, 2011. Notary Stamp or Seal: Signature of Notary Public Printed Name of Notary Public My Commission Expires: EXHIBIT A BEING KNOWN and designated as Lot No. 8,Block B,of Richardson Estates Subdivision,as set forth in Plat Book 4,Page 31,Davie County Registry,to which reference is hereby made for a more particular description. TOGETHER WITH a septic repair easement and right of ingress and egress across Lot 7,Block B, of Richardson Estates Subdivision,as set forth in Plat Book 4,Page 31,Davie County Registry,as is necessary to repair the septic tank located on Lot 8 described herein. SUBJECT TO easements and restrictions of record. FOR BACK TITLE,see DB 511,PG 847,Davie County Registry. See also Tax Map H-3-4,Blk A,Pcl 13, located in Mocksville Township,Davie County,North Carolina. NTE/TAF X:/My Files/TAF/Real Est/Whitlock,Jane,Deed to Ashley and Alex r _ APPLICATION FOR SITE EVALUATIONAMPROVEMENT P Davie County Health Department Environmental Health Section . 11997 P.O. Box 848 Mocksville,NC 27028 (704) 634-8760 —t-- ****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. 1. Name to be BilledContact Person Mailing Address 3— n t-E Zh4,-A -renk /n, Home Phone City/State/Zip mcc hsu /10-- �� �2'X��B' Business Phone S 2. Name on Permit/ATC if Different than Above Mailing Address City/State/Zip 3. Application For: [ ] Site Evaluation [ ]Improvement Permit&ATC [y-B6th 4. System to Serve: [LpFlouse [ ]Mobile Home [ ]Business [ ]Industry [ ] Other 5. If Residence: #People #Bedrooms_- #Bathrooms ^)Dishwasher[ ]Garbage Disposal �J Washing Machine [ ]Basement/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 V J Vell [ ]Community 8. Do you anticipate additions or expansions of the facility this system is intended to serve? [ ]Yes V rNo If yes,what type? EITHER A PLAT OR SITE PLAN PROPERTY INFORMATIO IRED:***IMPORTANT***A OF THE PROPERTY MUST BE 1'76SUBMITTED WITHLlHqS APPLICATION. Property Dimensions: WRITE DIRECTIONS(fromocksville)TO PROPERTY: Tax Office PIN: #5-N 9_-/' _-1/ Property Address: Road NameTG//�/ 2i/� V City/Zip ,�z&-Z/Z Z4L ; T1= -Ag If in Subdivision provide information,as follows: !?I✓ L7� �!'► (��'k'r Name: CL=&n/ STrS' Section: Lot#: ; 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 -Aq conduct all testing procedures as necessary to determine the site suitability. DATE ' ? SIGNATURE ` Revised DCHD(06-96) THIS AREA MAY BE USED FOR DRAIVINC7 YOUR SITE FLAN: • , DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section SECTION LOT Soil/Site Evaluation APPLICANT'S NAME 'Ael 'b✓ DATE EVALUATED PROPOSED FACILITY PROPERTY SIZE J/, r SUBDIVISION 1` VCS ROAD NAME ] I(5 t•� R- Water Supply: On-Site Well el Community Public Evaluation By: Auger Boring L/ Pit Cut FACTORS 1 2 3 4 5 6 7 Landscape position .L Sloe% HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH Texture group Consistence ; Structure IK 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- 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) ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■csee■■■■■■■■//■■//■■■■/■■■■■■■■■■■■■■■■//■ecce■■■■■■■■■■■■/■■■■■ ■/■■■/■■■c■■■/■■ec■■■■c■■■/un■■■ a■■e■/■■■/■■■c■■/■■■■■■■■■■■■■■■ iiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiii::::::■■///■■■■/■/■■/■■■■/■■■■■■/ ■■■■■■■■■■■■■■■■■■/■■■■■/■r.:�■/■■viii■■■■■■■■■■/e■■//■■■■■■■■■/■■■ MENNENMONSONMENNEN ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■