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153 Fernhaven Lane Lot 6Davie County, NC Tax Parcel Report Wednesday. December 28. 2016 131 �o I 3781 3 771 3763 109 119 125 1141 133 1 i 374315 3750 35� 3730 _3 _37,14 3706 91 v►� All data Is provided as Is without warranty or guarantee of any Idnd 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 Davie 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 nO�p C� N`'�r or arising out of the use or Inability to use the GIS data provided by this websfte. WARNING: THIS IS NOT A SURVEY Parcel Information Parcel Number. E60000002406 Township: Farmington NCPIN Number. 5851827772 Municipality: Account Number. 82532041 Census Tract: 37059-803 Listed Owner 1: FLIPPIN MICHAEL D Voting Precinct: SMITH GROVE Mailing Address 1: j 153 FERN HAVEN LANE Planning Jurisdiction: Davie County City: MOCKSVILLE Zoning Class: DAVIE COUNTY R -A State: NC Zoning Overlay: DAVIE COUNTY QD Zip Code: 27028-0000, Voluntary Ag. District: No Legal Description: LOT 6 RICHARD SHORT PROP Fire Response District: SMITH GROVE Assessed Acreage: 6.85 Elementary School Zone: PINEBROOK Deed Date: 6/2010 Middle School Zone: NORTH DAVIE Deed Book / Page: 008290421 Soil Types: MrB2,IrB,EnB,MsC Plat Book: 0008 Flood Zone: Plat Page: 140 Watershed Overlay: DAVIE COUNTY Building Value: Outbuilding 8r Extra Freatures Value: Land Value: Total Market Value: Total Assessed Value: 91 v►� All data Is provided as Is without warranty or guarantee of any Idnd 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 Davie 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 nO�p C� N`'�r or arising out of the use or Inability to use the GIS data provided by this websfte. APPLICANT INFORMATION Account #: 990005527 Billed To: Michael Flippin Reference Name: Michael Flippin Proposed Facility: Residence DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/ Site Evaluation PROPERTY INFORMATION Tax PIN/EH #: 5851-82-7772 Subdivision Info: Fkm lwt x-04 Location/Address: Fern Haven Ln- 27028 Property Size: 6.86 i Date Evaluated: �e —1 Z� Water Supply: On -Site Well Community Evaluation By: Auger Boring Pit Public Cut SITE CLASSIFICATION: 1-'S LONG-TERM ACCEPTANCE RATE- © • REMARKS: EVALUATION BY - OTHER( S) Y:OTHER(S) PRESENT: / /r !!?Uz l cr S 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 VFR - Very friable FR - Friable FI - Firm VFI - Very firm EFI - Extremely firm NS - Non sticky SS - Slightly sticky S - Sticky VS - Very Sticky NP - Non plastic SP - Slightly plastic P - Plastic VP - Very plastic 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 ]�otec 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) TTAR - T.nna_tP.rm arrP.ntanrP rate - anVilav/ftp TNf T71%none m__-:__�� Landscape position ..- •. `ice"���_ HORIZON�--- DEPTH Texture group Am��N@� W3171—Am Consistence HORIZON H DEPTH -Te Consistence Mineralogy HORIZON III DEPTH �roup_ -Texture HORIZON IV DEPTH IMM" groupConsistence Texture Consistence 7 SOIL WETNESSRESTRICTIVE HORIZON SAPROLITE CLASSIFICATION SITE CLASSIFICATION: 1-'S LONG-TERM ACCEPTANCE RATE- © • REMARKS: EVALUATION BY - OTHER( S) Y:OTHER(S) PRESENT: / /r !!?Uz l cr S 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 VFR - Very friable FR - Friable FI - Firm VFI - Very firm EFI - Extremely firm NS - Non sticky SS - Slightly sticky S - Sticky VS - Very Sticky NP - Non plastic SP - Slightly plastic P - Plastic VP - Very plastic 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 ]�otec 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) TTAR - T.nna_tP.rm arrP.ntanrP rate - anVilav/ftp TNf T71%none m__-:__�� PLICATION FOR SITE EVALUATIONMHROVEMENT PERMIT & ATC �y O Davie County Environmental Health P.O. Boz 848/210 Hospital Street V� Mocksville, NC 27028 (336)753-6780/ Fax (336) 753-1680 do r: GI'Site Evaluation/Improvement Permit ❑ Auth99nnation To Construct(ATC) ❑ Both i e pplication: ❑New System ❑Repair to Existing System SExpansion/Modification of Existing System of 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 MiAlood - 1 n Contact Person tlichad o h d Je'11'l4r Billing Address Home Phone �� City/State/ZIP - Business Phone L Name on Permit/ATC if Different than Above 1� a+ka.rl `% or � / R, Gha.rd Sh or Mailing Address /53 Ff rn Ha vr..rt ( n. City/State/Zip MCKSVI lit, tY- 2102 ` YKVYCKIY 1NI'VKNIAIWN 1 11)ate House/Facility Comers Flagged 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 o. d SSI Q tS hoY t Phone Number Owner's Address rti l4ewen bn City/State/Zip fY)J)Gr�Vl r� Property A ss City L Z70 Z Lot Size ' Tax PIN# — 7 Subdivision Name(if applicable) Section/Lot#_� Directions To Site: H WU 1.58 -1'o Feprt HeNi If the answer to any of the following questions is `ryes", supporting docurn9tation must be attached. Are there any existing wastewater systems on the site? Ryes ❑No Does the site contain jurisdictional wetlands? Dyes PNO Are there any easements or right-of-ways on the site? ❑Yes ❑No Is the site subject to approval by another public agency? Dyes w�o Will wastewater other than domestic sewage be generated? ❑Yes BiQo IF RESIDENCE FILL OUT THE BOX BELOW # People or# Bedrooms 3f # Bathrooms 2 Garden Tub/Whirlpool ❑Yes ❑No Basement: ❑Yes o BasementPlumbine: ❑Yes )Wn . 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: 4onventional Accepted ❑Innovative ❑Alternative ❑Other p �� M A .JUN qn t1 A, Water Supply Type: ❑County/City Water ❑New Well *sting Well ❑Community Well � � Gh�1i , D► , SS CV q 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. 1 understand that any permit(s) or ATC(s) issued hereafter arc subject to suspension or revocation if the sits, is ultrrcd. the intcndtxt urs, changcs, or ifthe information submitted in this application is falsified or changed. 1 hereby _*rant right ofentryto the Authorized Rcprvwnt ativu uraic Davie Ccnanty livull'n ih7r,.rrin+cr+t to cunt rct ;+tct%, xwy itrspwtiuns to determine compliance with applicable laws and rules. I understand that I am responsible for the proper identification and labeling of property lines and iltl,• corners and W40in a apt;int> nr t tEat ir.^ tht: E+n ? 'fx:I+••,,•ti ,.... ta. Site Revisit Charge Property o er's or er's legal te resentative signature &% Client j!D ): Client Notification Date: Date � (1 �) �U � � IIiS: Si ver ❑Y r L Sign given es ❑No � p �]� Account # lJ 3 L n r r� Revised 11/06 D Invoice # I Re Pr( Q----------------- **N4 40T authorize the construction of a septic tank system or any wastewater EWATER SYSTEM CONSTRUCTION must be obtained from this ion 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 "W Ste. #People I #Bedrooms 3 #Baths 2 -- ental Health Section '848/210 Hospital Street eksville, NC 27028 (336)751-8760 . NVT/OPERATION PERMIT Tax PIN/EH #: 5851-82-7772 Subdivision Info: Fam.Div R. Short Lot # 6 Location/Address: Highway 158-27028 Property Size: 7 acres Dishwasher: li- Garbage Disposal: ❑ Washing Machine: Basement w/Plumbing: 1 " Basement/No Plumbing:.❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size �"1'iS Type Water Supply IA3E' —' Design Wastewater Flow (GPD) �Q Site: New ®" Repair ❑ -WAL. Pump Tank GAL. Trench Width Rock Depth 2 Linear Ftp System Specifications: Tank Size 1 "' Other: 4al 6ptL!� Required Site Modifications/Conditions: )n s -TALL, Ont Lo-ho'A �LEir,P JS n (- T'f � �CO IQs^^ O'*L- IMPROVEMENT/OPERATION PERMIT LAYOUT - Al FINISHED GRADE. ****NOTICE: Contact a representati system between 8:30 a.m. to 9:30 a.m. or 1:00 p.m. to 1:30_v4. I ZZ Environmental Health Specialist's DCHD 05/99 (Revised) FILTER RISER(S) IF 6 " BELOW -alth Department for final inspection of this w—Telephone# is 1336)751-8760.**** Date: ts- L7b4 S NOP . 2D '2-'S (r:U6 VAL HEAL.'1:1 P.O. moo`::< -l= Flo srii:e. NC Fax=(--=Gt7�,i-S"S6 AUMORIZA'TION FOR WASTEWATER SYSTEM CONSTRUCTION Account #: 990003217 Tax PIN/EH #: 5851-82-7772 Billed To: Richard Short Subdivision Info: Fam.Div R. Short Lot # 6 Reference Name: Location/Address: Highway 158-27028 Proposed Facility: Residence_ Property Size: 7 acres ATC Number: 3771 Site Tyle: -':\env =Repair -Expansion **NO'1'1'** 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, Scction .1900 Sewage Treahuent and Disposal Systems). TIIIS AUTHORIZATION TO CONSTIZUCT IS VALID FOR A PERIOD OF FIFE YEARS. This ATC is subject to revocation if site plans, plat or the intended use change. Residential Specifications: --Bedrooms i� E3at1.u•oom5�{ = Peonle_ Basement= Basement plumbing Non -Residential Specifications: Facility Type_-_ • ___ rt People__- = Seas__- Syuan! Footage(or Dimensions of Facility) -- Lot_ Lot Size -7/4 4wType of Water Supply: OCounty/City XIll JCornmunity Well System Specifications: Design Wastewater Flow (CTPD) .F- & Tank Size 1660 ,CTAL. Pump Tank GAL. Trench Width Ma -,. Trench Depth3_ Rock Dcpth� Linear Ft. 700 _ Si'e \Io;iificatiors Conditions -Other: ��� �J%d. F9ON\,- 1W F-90AAk 0OU- Contact the Davie Count- Environmental Health Section for final inspection of this sy%tent between 8:30 — 9:30a.m. on the dad' of installation. Telephone # (336)751-8760.' - le `.`� - i t Env: ro, imental Health Specialist -� �f • ,� 1 _ ._Date r 19Z, —_ 4 M ==" r;run t 1 ;n4 rn�..;;t,�t DAVI[E COUNTY HEALTH DEPARTMENT P. ®. Boz 848/210 Hospital Street Mocksville, NC 27028 Account #: 990003217 Tax PIN/EH #: 5851-82-7772 Billed To: Richard Short Subdivision Info: Fam.Div R. Short Lot # 6 Reference Name: Location/Address: Highway 158-27028 Proposed Facility Residence Property Size: 7 acres ATC Number: 3771 "F 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 I 1 of G.S. Chapter 130A, Wastewater Systems, Section -_1900 Sewage Treatment and Disposal Systems). THIS AUTHORIZATION FOR WAS O 'f RUC ION I VALID FOR A PERIOD OF FIVE YEARS. y Environmental Health Specialist's Signature: f 1, Date: = % '/ 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. f; % Septic System Installed By: Environmental Health Specialist's Signature: DCHD 05/99 (Revised) Date: Davie County, NC Property Record Card *SE6_KQ0.0_02406 _ __- 001FERNHAVEN.______.__ SHORT RICHARD C 153 FERNHAVEN LN 000066006000 DAVIE COUNTY (2009 REVAL) C FIRE CON NJx TION [ �.r.?._ LOT 6 RICHARD_S -APFRAISE D_��QZ09__OV272 .600,7j.Q3005_SMITHI G. FOUND * 3 CONT FOOTING * J I I I - SUBFLR* 4 PLYWOOD * 801 --01 1 080141 97.29 1-06,879070702000000 EX WL1* 10 ALUM/VINYL * 29SINGLE FAMILY RESIDENTIAL - SFR CONSTRUCTION RF STR* 03 GABLE * 8SCALE 1/214 STORIES 02 1.5 STORIES RF CVR* 12 MOD MET/MET * ---T --. INT W1* 5 DRYWALL * 2� FLOORI* 12 HARDWOOD * 100 I-1 III +-----24------+ FLOOR2* 14 CARPET * 1 IFUS I FUEL * 04 ELECTRIC * I^ -' I HEAT * AC * 10 HEAT PUMP * y - BEDRMS* 03 CENTRAL BAS-OFUS-ILL- 0 * 4 4{ I I Cs u�Ftif t BATHS * BAS-IFUS-OLL- 0 * 4 +-----29------+ QUAL DESIGN*QUAL*SIZE * 9� ABAVG 1.05 1.20 1.14=*1.44 TOTAL QUALITY INDEX * 14l +-----24-----+ GS AREA PCT RPL CS 576 035 19,65 576 100 56,03 336 090 29,38 Ell I _EP.L___21, 988F-IBTl_ , 8 --I-1-1- 02GARAGE 1 50 2$$ 115680 24ISHED 4 119 4620 IIS ill 2 opqj� f)C)f 2 +-----24-----+ IBAS I I I 2 2 I I I I +-----24-----+ I`F�O P I 2 2 I I Page 1 of 1 FRI SHJANT_RIC20R0,� 3:3( E6 000 00 024 b6 Map S/M Bk Lot SP1 ID NO: 5851827772 CARD NO. 1 OF 1 6,-86AC-_ _ _- _ 0.000 SRC= 4: DPPR BLDG Ve I[jE _-- .._-MARKET_ _ 1281 46 179, _ 179, 179, PRIOR PERMIT INFO 51,180 122,740 --- 07400471161207WD ';EI 105WD GV 052�0361fo�03WD XV, _-- 2400000 040403 X08 26, �j 04!05 07 1, 55� gg $OE24N24$4PTREN20 FUS=N19E24S14W24$S20$. l i l I I M rr� Gt.-t� �--�II----- RO 15+00-10+OOP 8,50000 - - 6861iA� 791-_ 6,7320 46,1881 ND N( - ---- ----6861- ----- --- 96190 Bclrnti l3G�1_ http://maps.co.davie.nc.us/davieprcldaviencICreatePRC_2.pll?Card=1 &recNum=E6000O00... 6/4/2010 ---1- --1---1-7 ---T --. - -- --- - RURAL AC 10121 1210906 I-1 III M rr� Gt.-t� �--�II----- RO 15+00-10+OOP 8,50000 - - 6861iA� 791-_ 6,7320 46,1881 ND N( - ---- ----6861- ----- --- 96190 Bclrnti l3G�1_ http://maps.co.davie.nc.us/davieprcldaviencICreatePRC_2.pll?Card=1 &recNum=E6000O00... 6/4/2010 A °26'03"E 801 /08 s 40/./2' 5i8'REBAR SET QQ co h� rij oh Jr ;' t c w A cn �i 5/8" REBAR SET tD O O N W M o O O O Z ' . 5/8, REBAR SET N 84' "W 7' / h' I M DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990003217 Tax PIN/EH #: 5851-82-7772 Billed To: Richard Short Subdivision Info: Fam.Div R. Short Lot # 6 Reference Name: Location/Address: Highway 158-27028 Proposed Facility: Residence Property Size: 7 acres Date Evaluated: Water Supply: On -Site Well Community Public Evaluation By: Auger Boring V/ Pit Cut FACTORS 1 23 4 5 6 7 Landscape osition L Sloe % HORIZON I DEPTH - ILP- I O- O Texture group: G!, GL. Consistence Structure uWL Mineralogy HORIZON II DEPTH Ito I ZS -40 - i Texture grou a'to Consistence : F, Structure k M MineralogyX hMA t 1. EV HORIZON III DEPTH -4 Texture group Cstence Stricture -Mineralogy C.{ ooQ.9 n IYOU M1> HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE Z SITE CLASSIFICATION: P$ - LONG-TERM ACCEPTANCE RATE: C) - REMARKS: LEGEND Landscape Position EVALUATION BY: sl.I,' rZz,t1' p OTHER(S) PRESENT: 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 DC14D 05/99 (Revised) - DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990003217 Tax PIN/EH #: 5851-82-7772 Billed To: Richard Short Subdivision Info: Fam.Div R. Short Lot # 6 Reference Name: Location/Address: Highway 158-27028 Proposed Facility Residence Property Size: 7 acres ATC Number: 3771 **NOTE** This Improvement/Operation Permit DOES NOT authorize the construction of 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 I #Bedrooms 3 #Baths 2 -- Dishwasher: Rf- Garbage Disposal: ❑ Washing Machine: Basement w/Plumbing: C3 Basement/No Plumbing: 13 Commercial Specification: Facility Type ^ #People #People/Shift #Seats Industrial Waste: Lot Size � �"riS Type Water Supply (atc-1 _ Design Wastewater Flow (GPD) �2�O0 Site: New 0'/ Repair System Specifications: Tank Size 1 L^'`-(3AL. Pump Tank GAL. Trench Width Rock Depth 2 Linear Ft!CCY- Other: /LO 6o<Le:,� Required Site Modifications/Conditions: )n3Si4Lj- Or,� CQ—h000- IMPROVEMENT/OPERATION Q"h0 IMPROVEMENT/OPERATION PERMIT LAYOUT - FINISHED GRADE. ****NOTICE: Contac system between 8:30 a.m. to 9:30 a.m. or 1:001 4— Environmental — Environmental Health Specialist's DCHD 05/99 (Revised) FILTER RISERS) IF 6 " BELOW Department for final inspection of this Felephone # is 1336)751-8760.**** 140ose 135' S Nor) Date: v 20_ 2.S' APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC Davie County Health Department Environmental Health Section P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (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 /L iz l,A-.// --� n G r—A Contact Person Mailing Addressi/ ler S -f- Home Phone / / 6 ' / City/State/ZIP 1_LS L&11�G lain. 7/63 1- Business Phone 67- 4,:2-� 2. Name on Permit/ATC if Different than Mailing Address 3. Application For: ❑��Site Evaluation 4. System to Service: 2"House ❑ Mobile Home ❑ Business S. Type system requested: 121 Conventional ❑ conventional modified City/State/Zip LImprovement Permit/ATC ❑ Both ❑ Industry ❑ Other ❑ innovative 6. I 2 ��f Residence: # People / # Bedrooms — ElDishwasher []Garbage Disposal E Washing Machine OTa.ement/Plumbing 7. If Business/Industry /Other: verify type # People # Commodes # Showers # Urinals # Bathrooms ❑ Basement/No Plumbing # Sinks # Water Coolers IF FOODSERVICE: # Seats Estimated, Water Usage (gallons per day) 8. Type of water supply: 11County/City L�'Well ❑ Community 9. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes 9 -No If yes, what type? ***IMPORTANT*** CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BE SUBMITTED by the client with THIS APPLICATION. Property Dimensions: 7 q L Tax Office PIN: # S;5.S% ID 77 -12 - Property 7- 2 - Property Address: Road Name City/Zip If in a Subdivision provide information, as follows: Name: Fat -41 ��, �,� ✓ r S / c � P13 g P� sg 6 Section: Blo . Lot: WRITE DIRECTIONS (from Mocksville) to PROPERTY: /04 Z92 4 A,/ ri Date home corners flagged: Is 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 responsihle for all charges incurred froul 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 su�itabili�ty.-- DATE �{ - a SIGNATURE THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (Include all of the following: Existing and proposed property lines and dimensions, structures, setbacks, and septic locations). r �,' 1� Sign given Revised DCHD (05/03 Site Revisit Charge Date(s): r aAL- Client Notification Date: EHS: Account No. � Invoice No. APPLICANT INFORMATION Account #: 990003217 Billed To: Richard Short Reference Name: Proposed Facility: Residence Water Supply: Evaluation By: On -Site Well DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation PROPERTY INFORMATION 2 Tax PIN/EH #. 5851-82-777 Subdivision Info: Fam.Div R. Short Lot # 6 Location/Address: Highway 158-27028 Property Size: 7 acres Date Evaluated: //1 s kV Community Public Auger Boring ✓ Pit Cut FACTORS 1 2 3 4 5 6 7 Landscape position L L Slope % $'-wo HORIZON I DEPTH — t to —1y O^ 4 Texturerou ; G V 64- Consistence Structure 1L. Mineralogy xa., Mn..U5D HORIZON II DEPTH 1 6-40 — t Texture grou C_ Consistence + F, Structure L M Mineralogy X mt � HORIZON III DEPTH —4 rg _V M. Textqrerou ', Lt P..9 Gt Consistence F; r Structure 3 FV_ M neralo M / 1t HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE. Z .71 SITE CLASSIFICATION: LONG-TERM ACCEPTANCE RATE: REMARKS: EVALUATION BY: STI Zq= A'p OTHER(S) PRESENT: _ 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 Mois 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 05/99 (Revised) °26'03 " . 08- 108. 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