245 Tall Timber Dr OPERATION PERMIT or Ificeuseluniy
Davie County Health Department *CDP Fite Number 187522-2
T.
210 Hospital Street F2-000-00-027-01
P.O.Box 848 County ID Number.
Mocksville NC 27028 Evaluated For. NEW
Phone:336-753-6780 Fax:336-753-1680 Township:
Applicant: Charles Birdsong Property Owner- Charles Birdsong
Address: 109 Spruce Street Address: 109 Spruce Street
City: Mocksville City: Mocksville
State/Zip: NC 27028 StatetZip: NC 27028
Phone#: (828)464-2662 Phone#: (828)464-2662
Property Location & Site Information
Address/Road#: Subdivision: Phase: Lot:
245 Tall Timber Drive
Mocksville NC 27028 Directions
Structure: SINGLE FAMILY 64 West, Sherfield Rd. to Georgia Rd. to Tall Timber
Dr
#of Bedrooms: 3
#of People:
*Water Supply: NEW WELL
*IP Issued by. 2140-Natrons,Robert *System Classification/Description:
TYPE It A.CONY SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS)
*CA issued by: 2140-Nations,Robert Saprolite System? QYes (BNo
Design Flow: 3 6 0 * GRAVITY-SERIAL. Pump Required?
Distribution Type: (, Yes ONo
Soil Application Rate: 0 3 *Pre Treatment:
Drain field
rNo.
cation Field 1 a 0 0 SQ *System Type: INFILTRATOR QUICK 4 STANDARD
rain Lines 4 Installer: Sherman Dunn
Total Trench Length: 3 0 0 d• Certification#: 2702
Trench Spacing: 9 gFe t O.C.O.C.
THS: 2140•Nations.Robert
Trench Width: _ 3 Olnches
a Feet Date: 0 5 / 2 8 / .1 0 1 5
Aggregate Depth: inches
Minimum Trench Depth: 3 6
Inches
Minimum Soil Cover. a 4 ApprovalStatus'
Inches
Maximum Trench Depth: 3 6 Inches ® Approved CI Disapproved
Maximum Soil Cover. 2 4 Inches
CDP Fite Number 187522 -2 County ID Number: F2-0a0-oa027-o1
Septic Tank
Manufacturer. Shoaf Lata
STB: 760
Long:
Gallons:
1000 Installer. Sherman Dunn
Certification#: z�o2
Date: 1 a / 0 5 / a 0 1 4
EHS- 2140-Nations.Robert
'Filter Brand: POLYLOKPL-122 With Pipe Adapter
ST Marker. El Yes ❑ No
Date: 0 5 / a 8 / a 0 1 5
LAW
Reinforced Tank: El Yes ❑ NoAl
Approval Status
Piece Tank: El Yes
❑ No ® Approved❑ Disapproved
Pump Tank
Manufacturer. Installer
PT: Certification#:
Gallons: *EHS:
Date: / / Date:
RiserSealed ❑ Yes ❑ No
RiserHeght: C3 Yes ❑ NO (Min.6 in.) Approval Status
Reinforced Tank: ❑ Yes ❑ No p Approved❑ Disapproved
1 Piece Tank: ❑ Yes ❑ No
Supply Line
CPipe Size: inch diameter Installer
Pie Length: feet Certification#:
*Schedule: *EHS:
Pressure Rated ❑ Yes ❑ No Date.
Approved fittings ❑ Yes ❑ NO Approval Status
A roved❑ Disapprovetl
pp al
Pump em e
Pump Type. Installer.
Dosing Volume: - Gal Certification#:
Draw Down: Inches *EHS.
*Chain:
- Date:
Valves Accessible ❑ Yes ❑ No
Flow Adjustment Valve ❑ Yes ❑ No
Check-valve El Yes ElNO Approval Status z
PVC unions EJ Yes Q No ❑.App11 roved,0 Disapproved
Vent Hole ❑ Yes ❑ No
An
Hole ❑ Yes ❑ NO
CDP File Number 187522-2 County ID Number: F2-000-00-027-01
Electric Equipment
NEMA4XBoxorEquivalent ❑ Yes ❑ No Installer:
Box 12 inches Above Grade ❑ Yes ❑ No
Certification 9:
Box Adj. Pump Tank ❑ Yes ❑ No
Conduit Sealed ❑ Yes ❑ No *EHS:
Pump Manually Operable ❑ Yes ❑ No
*Activation Method: Date:
Approval Status
I=A ib ❑ Yes ❑ NO T j
❑ Approved❑ Disapproved
Alarm visible ❑ Yes ❑ NO
2140-Nation,Robert
*Operation Permit completed by
Authorized State Agent: Date of Issue: 0 5 / 2 8 / 2 0 1- 5 .
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 property is served by a TYPE 11,k sewage septic system.
Rule.1961 requires that a Type TYPE 11 A. septic system meet the following criteria:
Minimum System Review By The Local Health Department: WA
Management Entity: OWNER
Minimum System Inspection/Maintenance Frequency By Certified Operator:
NIA
Reporting Frequency By Certified Operator. WA
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 entitywth a certified operatoror a private certified operator forthe life of the septic system.
Rule.1961 requires that Type VI septic systems designed fora home/business owner must maintain a valid contract with a
public management entitywith 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 envy, 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.
OHand Drawing Olmport Drawing
**Site Plan/Drawing attached.** `"
OPERATION PERMIT
Davie County Health Department CDP File Number: 187522 2.
210 Hospital Street F2-000-00-027-01
P.O.Box 848 County File Number:
Mocksville NC 27028 Date: 1 /
Olnch
Drawing Drawing Type: Operation Permit Scale: ON o k ft.
O
eco �
G
,
I I I
-17
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1
Well Construction Permit For office Use Ont
Davie County Health Department *CDP File Number 187522
• 210 Hospital Street PIN Number. 172-000,00-027-01
P.O.Box 848
Mocksville NC 27028 Tax Lot M Tax Block#:
Phone:336-753-6780 Fax:336-753-1680 Evaluated For.WELL
PERMIT VALID UNTIL: 3/18/2020
PropertyOwner. Charles Birdsong Applicant: Charles Birdsong
Address: 109 Spruce Street FAddress: Tall Timber Dr
CRY: Mocksville City: Mocksville
State/Zip: NC 27028 State/Zip: NC 27028
Phone M Phone#:
Property Location & Site Information
ress/Road M �q Subdivision: Phase: Lot:
of Tall Timber Drive *Proposed use of Well:
cksville NC 27028
Directions If Other.
Site Address:Off of Tall Timber Drive Directions:64 West,Sherfield Rd.to Georgia Rd.to Tall
'Timber Dr
Well Contractor Information
Drilling Contractor Driller Registration
k. 4up 14
ZY 2-
Permit Conditions
*Permit Conditions
Well location,construction and protection must meet all state and local regulations and must be Inspected and approved by an authorized representative of
the Local Health Department.The permit may be revoked at any time for failure to complywith existing regulations.The slung or approved well construction
area(s)by the Health Department Is to provide protection from the known possible sources of contamination.The approved well areas)may not be changed
without written permission from an authorized representative of the Local Heatm Department.No volume of quality of water Is guaranteed by the Health
Department.
*Issued By: 2140-Nations, Robert *Date of Issue; 0 , 3 / 1 1 8 / ' .2 1 0 . 1 , 5
Authorized State Agent: @Hand Drawing OlmportDrawing
Owner/ApplicantSignatur . **Site Plan/Drawing attached.**
WELL CONSTRUCTION PERMIT
Davie County Health Department CDP File Number: "I$7522�
a'" o #
210 Hospital Street' F2-000=00-o27-01
P.O.Box 848 County File Number.
Mocksville NC 27028 Date' 03 / 18 / .1 0 1 5
Q inch
Drawing Type: Well Permit Scale: , pslock �y
ONip
F7 1
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\ WELL CONSTRUCTION PERMIT 187522
Davie County Health Department CDP File.Number
a `���
Zi0 Hospital Street
210Box 848 County File Number. F2.000.00.427.01
Mocksville NC 27028 Data: 0 3 1 1 8 I a 0 1 5
� �nI
RMN`�
Olnch
Drawing Type: Well Permit Scale: OBlock
ON/Aft.
i_ ------416
— — ' 41_ --
APPLICATION FOR PRIVATE WELL PERMIT
pAVD Davie County.Environmental Health
P.O.Box 848/210 Hospital Street
p�tl►t Mocksville,NC 27028
(336)753-6780/Fax(336)753-1680
***IMPORTANT***
THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED.
E
APPLICANT INFORMATION
Name C6� ��> U� r-j- g o„< <., _ Contact Person Ct-�tr2s
Address Home Phone
City/State/ZIP tau G X7 Business Phone
Name on Permit if Different than Above
Mailing Address 'City/State/Zip
PROPERTY INFORMATION *Date House/Facility Corners Flagged
NOTE: A survey plat or site plan must accompany this application. Included: ite Plan ❑Plat(to scale)
Owner's Name cS'i Me— Phone Number
Owner's Address City/State/Zip
Property Address // /`h2 AL �7 ,. City
Lot Size Tax PIN#
Subdivision Name(if applicable) Section/Lot#
Directions To Site:
- ---DEVELOPMENT INFO - -- ON - - - - ----- -- - --
Permit Type: New Well Well Repair Well Abandonment Other(specify)
Facility Type: Residential Food Service Church Commercial Other
Are There Any Septic Systems Currently On The Site? YES NO
Do You Intend To Install A New Septic System On This Site? YES NO
TERMS AND CONDITIONS:
This application must be accompanied by a plat or site plan of the.property that includes the existing and proposed property lines
with dimensions,the specific location of the facility and any existing or future appurtenances,the location of any existing septic
system,sewer lines,water lines,any existing water supplies and any surface waters. The applicant is responsible for identifying
and marking the property lines and corners. The applicant is responsible for making the site accessible:
By signing this application,the applicant signifies that they understand the terns and conditions and that they give permission for
Davie County Environmental Health representatives to perform necessary field evaluations and procedures deemed necessary to
determine the b ion for a well.
Signed Date
Site Revisit Charge
Date(s):
Client Notification Date:
EHS:
7/30/09 Account#
Invoice#
CONSTRUCTION For office Use only
• ` CDP Fife Number 187522-2
AUTHORIZATION
Go=- - Davie Count Health Department F2-000-00-027-01
V"'. Y P County ID Number.210 Hospital StreetEvaluated Fora NEW
P.O. Box 848 Township:
Mocksville NC 27028 PERMIT VALID UNTIL
Phone:336-753-6780 Fax:336-753-1680 0 3 / 1 8 a 0 a 0
Applicant: Charles Birdsong Property Owner: Charles Birdsong
Address: 109 Spruce Street Address: 109 Spruce Street
City: Mocksville City: Mocksville
State/Zip: NC 27028 State0p: NC 27028
Phone#: (828)464-2662 Phone#: (828)464-2662
Property Locatiite Information
rAddress/Road#: Subdivision: Phase: Lot:
l Timber Drive
e NC 27028 Directions
Structure: SINGLE FAMILY 64 West, Sheffield Rd. to Georgia Rd. to Tall Timber Dr
#of Bedrooms: 3
#of People:
'Water Supply: NEW WELL
System Specifications
Minimum Trench Depth:
rDesigan
Classification: Provisionally Suitable a _ Inches
Minimum Soil Cover.
System? OYes ®No 1 a Inches
low: 3 6 0 Maximum Trench Depth: 3 6 Inches
Soil Application Rate: 0 _ 3 Maximum Soil Cover: a 4 Inches
*System Classification/Description: 'Distribution Type:
TYPE Il A.CONV SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS) Septic Tank:
1 0 0 0 Gallons
`Proposed System: 250%REDUCTION 1-Piece; Oyes ONo
Pump Required: OYes @No 0May Be Required
Nitrification Field 1 a 0 0 Sp ft Pump Tank: Gallons
No.Drain Lines 3 1-Piece:OYes ONo
Total Trench Length: 3 0 0 ft GPM vs— ft. TDH
Trench Spacing: Inches O.C.
— 9 . Feet O.C. Dosing Volume: _ Gallons
Trench Width: _ Inches
3 Feet Grease Trap: Gallons
Aggregate Depth: inches Pre Treatment: ONSF OTS-1 OTS-II
Septic Tank InstallerGrade.Level Required: 01011 0111 DIV
Pana 1 of 2
172-000-00-027-01
CDP File Number 187,522 - 2, County ID Number. 1#
❑ Open Pump'System Sheet
Repair System Required:eYeS ONo ONo, but has Available Space
e2air System
Trench Spacing: Q Inches O.
'Site Classification: Provisionally Suitable 9 ®Feet O.C.
Trench Width: Inches
Design Flow: 3 6 0 — 3 - Feet
Soil Application Rate: 0 - 3 Aggregate Depth: inches
Minimum Trench Depth: a 4
*System Classification/Description: Inches
TYPE II A.CONV SYSTEM(SINGLE-FAMILY OR 480,GPD-OR LESS) Minimum Soil Cover: '1 a Inches'
Maximum Trench Depth: 3 6 Inches
'Proposed System: 25%REDUCTION -
Maximum Soil Cover. a 4
Nkrification Field 1 a 0 Inches
Sq.ft.
No. Drain Lines 3 "Distribution Type: GRAVITY-SERIAL
Total Trench Length: 3 '0 0 ft. Pump Required: Oyes, ONo, OMay.Be Required
Pre-Treatment: ONSF OTS-1 OTS-11
*Site Modifications
No grading or construction activity is allowed in,areas designated for system and repair without approval of Health Department.
"Permit Conditions
The issuance ofthis permit bythe Health Department in nowayguarantees the issuance of other permits.The permit holder
is responsible for checking with appropriate governing bodies in meeting their requirements.
This Authorization forwastewater System Construction shalt bevalld for a person equal to the period of validity of the Improvement permit not
to,exceed five years,and may be Issued atthe sxnetime the ImprovementPermIt Issued(NCOS 130A-336(b)) N the Installation has not been
completed during the period of validity of the constriction Permit,the Information submitted in the application fora permit or Construction
Authorization is found to have been incorrect falsMed or changed,or the site is altered,the permit orConstructlon Authorization shall become
Invalid,and may besuspended or revoked(.1937(g)).The person owning or controlling the system shall be responsible forassuringcompliance
with the laws,rules,and permit conditions regarding.system location installation,operatlon,maintenance6 monitoring,reporting and repair
ApplicanVLegal Reps.Signature Required? Oyes ONO
Applicant/Legal Reps.Signature' Date:-
* 2140-Nations,Robert 0 3 / 1 8 I a 0 1 5
Issued.By: Date of Issue:,._..�, - - - - - - - -
Authorized State Agen Malfunction Log OYes
@Hand Drawing Oimport Drawing
**Site Plan/Drawing attached.**
Page 2 of 3
CONSTRUCTION AUTHORIZATION 187522-2
Davie County Health DepartmentCDP File'Number:
210 Hospital Street F2-000-00-027-01
P.O.Box 848 County File Number:
Mocksville NC 27028 Date: 03 / 3. 8 / 2015
Q Inch
Drawing Drawing Type: .Construction Authorization Scale: . . . pneiA k ft.
pv
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b Pi
f- _
r IMPROVEMENT PERMIT For office Use only
r_ *CDP File Number 187522- 1
.� 1 Da4ie County Health Department
� 210 Hospital Street
County ID Number: F2-000-00-027-01
P.O. Box 848 Evaluated For: NEW
Mocksville NC 27028 Township:
Phone: 336-753-6780 Fax: 336-753-1680
PERMIT VALID UNTIL: 1/9/2020
*NOTE TO INSPECTIONS DIVISION: Building Permits cannot be issued with this Improvement Permit.
Applicant: Charles Birdsong Property Owner: Dana Stanley
Address: 16q 5p rlit4e '5'' Address:
City: /Vlk�v�61� /UG City: PAID
State/Zip: NC State/Zip:
Phone#: Phone#:
Property Location & Site Information
Address/Road#: Subdivision: Phase: Lot:
Off of Tall Timber Drive
Mocksville NC 27028 Directions
Structure: SINGLE FAMILY 64 West, Sheffield Rd. to Georgia Rd. to Tall Timber
#of Bedrooms: Dr
#of People:
*Water Supply: N/A
S stem S ecifications
Initial S stem
*Site Classification: Provisionally Suitable '
Minimum Trench Depth: a 4 Inches
Saprolite System? O Yes ®No
Maximum Trench Depth: 3 6 Inches
Design Flow: 3 6 0 Septic Tank:
1 0 0 0 Gallons
Soil Application Rate: 0 3 1-Piece: O Yes ®No
*System Classification/Description: Pump Required: OYes ®No O May Be Required
TYPE II A.CONV SYSTEM(SINGLE-FAMILY OR 480 GPD OR Pump Tank: Gallons
*Proposed System: 25%REDUCTION 1-Piece: O Yes O No
Repair System Required:®Yes ONo ONO, but has Available Space
Repair System
Rm
*Site Classification: Provisionally suitable Minimum Trench Depth: a 4 Inches
Soil Application Rate: 0 3 Maximum Trench Depth: a 8 Inches
*System Classification/Description: Pump Required: OYes ®No O May be Required
TYPE II A.CONY SYSTEM(SINGLE-FAMILY OR 480 GPD OR
LESS)
*Proposed System: 25%REDUCTION
Page 1 of 3
CDP File Number 187522 - 1 County ID Number: F2-000-00-027-01 • `
*Site Modifications ' ❑ Open Fill Sheet
No grading or construction activity is allowed in areas designated for system and repair without approval of Health Department. Reme'�9
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. Reme��g
750
The Improvement Permit shall be valid for 5 years from date of Issue with a site plan(means a drawing not necessarily drawn to
Site Plan scale that shows the existing and proposed property lines with dimensions,the location of the facility and appurtenances,the
O site for the proposed Wastewater system,and the location of water supplies and surface waters).
Plat The Improvement Permit shall be valid without expiration with plat(means a property surveyed prepared by a registered land
O surveyor,drawn to a scale of one inch equals no more than 60 feet,that includes:the specific location of the proposed facility
and appurtenances,the site for the proposed Wastewater system,and the location of water supplies and surface waters. Plat
also means,for subdivision lots approved by the local planning authority and recorded with the county register of deeds,a copy
of the recorded subdivisions plat that Is accompanied by a site plan that is drawn to scale).
The Department and Local Health Department may Impose conditions on the issuance and may revoke the permits for failure of
the system to satisfy the conditions,the rules,or this article.This permit is subject to revocation If the site plan,plat,or Intended
use changes(NCGS 130A-335(f)).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(A 938(b)).
Applicant/Legal Reps. Signature Required? Oyes O No
Applicant/Legal Reps. Signature Date:
Issued By: 2140-Nations,Robert Date of Issue: 0 1 / 0 9 / .2 0 1 5
Authorized State Agent: OValid without Expiration?
O Create CA?
®Hand Drawing O ImportDrawing
**Site Plan/Drawing attached.**
Page 2 of 3
IMPROVEMENT PERMIT
Davie County Health Department CDP File Number: 187522 - 1
• 210 Hospital Street F2-000-00-027-01
P.O.Box 848 County File Number:
Mocksville NC 27028 Date:
O Inch
Drawing Drawing Type: Improvement Permit Scale: , O Block
O N/A
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Page 3 of 3
P1 P2
IMPROVEMENT PERMIT
Davie County Health Department
210 Hospital Street CDP File Number: 187522 - 1
P.O.Box 848 F2-000-00-027-01
Mocksville NC 27028
County File Number:
Date: .0. 09 .2 0 1.5.
Click below to import an image from an external location: Drawing Type: Improvement Permit
Page 3 of 3 P1 P2
e7
RECEJVJ@JJ APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT&ATC
Jea
Davie County Environmental Rea lth. PAM
P.O.Box 848/210 Hospital Street
Mocksville,NC 27028 �W
(336)753-6780/Fax(336)713-;6
/ �'
Application For: 0 Site Evaluation/Improvement Permit A tl�or-za i To Co truct(ATC) KBoth
Type of Application: ONew System ❑Repair to Existing System Expansion/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 1
Name to be Billed Vt(s tf –P C, So�•�,Contact Person QLt u el 1C R;V'n I Sc MS'
Billing Address/ac? SE? Home Phone
City/State/ZIP -.0"0CBusiness Phone SAyv%e
Name on Permit/ATC if Different than Above SA(M 2
Mailing Address City/State/Zip
PROPERTY INFORMATION *Date House/Facility Comers Flagged
NOTE: A survey plat or site plan must accompany this application. Included:❑Site Plan ❑Plat(to scale)
(Permit is vali a�An mnnth�z with site plan,no expiration with complete plat)
Owner's Name(j !.sem Lt�(I-e--1 4 Phone Number
Owner's Address )A t—i ` l pH Ltj^4,c�&tfj City/State/Zip A C-/t- -e vtJ�
Property Address T J 10—p"5 Ot CityoC K< l(!o
—_ Lot Size Tax PIN# 4DaJ I (1l, F,
Subdivision Name(i app icable) Section/IC/-
Directions To Site:
If the answer to any of the following questions is`ryes",supporting documentation must be attached.
Are there any existing wastewater systems on the site? ❑Yes e(�
Does the site contain jurisdictional wetlands? ❑Yes C?N0
Are there any easements or right-of-ways on the site? Oyes 999
Is the site subject to approval by another public agency? ❑Yes G
Will wastewater other than domestic sewage be generated? ❑Yes o
IF RESIDENCE FILL OUT THE BOX BELOW
#People #Bedrooms #Bath��roo Garden Tub/Whirlpool❑Yes ❑No
Basement:❑Yes o Basement Plumbing: ❑Yes pyo
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: D6nventiona1 ❑Accepted ❑Innovative OAlternative OOther
Water Supply Type:❑County/City Water W<ewWell ❑Existing Well 0 Community Well
Do you anticipate additions or expansions of the facility this system is intended to serve?0 Yes 0 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 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 HilesA'ag
erstand that I responsible for the proper identification and labeling of property lines and comers and
loc ti g or a ng th ouse/facility location,proposed well location and the location of any other amenities.
Site Revisit ChargeProperty owner's or owner's legal represen ive signature
Date(s):
Client Notification Date:
Date EHS:
Sign given OYes ONo Account#
Revised 11/06 Invoice#
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# Page 1 of 1
Davie County,NC-GoMaps Advanced
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s- . DAVIE COUNTY HEALTH DEPARTW�NT !
Environmental Health Section
Soil/Site Evaluation
f
APPLICANT INFORMATION I
PROPERTY INFORMATION
IV& S�aA/&
� y r
I 3gAe, '
Water Supply: On- ite Well Community I}ublic
Evaluation By: Augj-,r Boring Pit �ut
1
FACTORS { 1 2 3 5 6 7
Landscape position
Slope% l ;L }
HORIZON I DEPTH j 12
Texture groupi 5 -- CL- t�
Consistence s j
Structure 4y ir I I
Mineralogyi
HORIZON H DEPTH I j
Texture group
Consistence j s i
i Structure
Mineralogy ! I
HORIZON III DEPTH
Texture group y Gag r 4,4-Aa
ConsistenceS P SS }
Structure j d I
Mineralo ( i
HORIZON IV DEPTH ? ►
Texture groupI
Consistence I I I
Structure M
Mineralogy { I '
SOIL WETNESS { f
RESTRICTIVE HORIZON II
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE ! i
M ,
SITE CLASSIFICATION: EVALUATIQN BY:
I
LONG-TERM ACCEPTANCE RATE: . OTHER(S)PRESENT:} C1.4,Atle I j D§l I
REMARKS:
a
LEGEND j
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 SII;-Silty loam CL-Clay loam SCL-Sandy clay loam
SC-Sandy clay SIC-Silty clay C-Clay f
fCONSISTLENCR
VFR-Very friable FR-FVable FI-Firm VFI-Very firm EFI-Extremely firm
NS-Non sticky SS-Slightly sticky S-Sticky VS-Very Sticky 1
NP-Non plastic SP-Slightly plastic P-Plastic VP-Very plastic I
i Structure 1
SC-Single grain M-Massive CR-Crumb GR-Granular ABK-Angular blocky;
SBK-Subangular blocky PL-Platy PR-Prismatic j
Mineralogy j
1:1,2:1,Mixed } i
Notes
Horizon depth-In inches ff
Depth of fill-In inches t
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) i
1
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