157 & 167 Docks Way Lot 6Davie Countv, NC
Tax Parcel Renort
Tuesday, January 3, 2017
Parcel Number:
NCPIN Number:
Account Number:
Listed Owner 1:
Mailing Address 1:
City:
State:
Zip Code:
Legal Description:
Assessed Acreage
Deed Date:
Deed Book / Page:
Plat Book:
Plat Page:
Building Value:
WAKNIINU: 'l'Hlb lb 1VU1- A JUKVEY
Parcel Information
M401 OA0006 Township: Mocksville
5726913991 Municipality:
69870000 Census Tract: 37059-801
SPILLMAN CLARENCE Voting Precinct: SOUTH CALAHALN
1949 JUNCTION ROAD Planning Jurisdiction: Davie County
MOCKSVILLE Zoning Class: DAVIE COUNTY R -A
NC Zoning Overlay: DAVIE COUNTY CZOD
Land Value:
Total Assessed Value:
27028-0000 Voluntary Ag. District:
LOT 6 GRANT HEIGHTS 3.552 ac Fire Response District:
3.55 Elementary School Zone:
8/2011 Middle School Zone:
008660454 Soil Types:
10 Flood Zone:
371 Watershed Overlay:
Outbuilding 8r Extra
Freatures Value:
Total Market Value:
No
COOLEEMEE
COOLEEMEE
SOUTH DAVIE
GnB2
DAVIE COUNTY
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, impliedwarranties of merchantability or fitness for a particular use. All users of Davie County's GIS website shall hold harmless the
' Countyof Davie, North Carolina, its agents, consultants, contractors or employees from any and all claims or causes of action due to +
NC or arising out of the use or Inability to use the GIS data provided by this websfte. I
UN j
�Xd
UTHORIZATION NO: DAVIE COUNTY HEALTH DEPARTMENT
. µ Environmental Health Section PROPERTY INFORMATION
Permittee's P.O. Box 848 t
Name: �'`'—�• Mocksville, NC 27028 Subdivision Name:r�
IF Phone #: 704-634-8760
Directions to property: "+t� ` - I t
���
Section: Lot: `
AUTHORIZATION FOR
WASTEWATER ,`, _ .�'
SYSTEM CONSTRUCTION Tax Office PIN:# '� � /f
Road Name: p:
**NOTE** This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior
to issuance of any Building Permits. This Form/Authorization Number should be presented to the Davie County Building Inspections
Office when applying for Building Permits.
(In compliance with Article l l of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED
***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
IS VALID FOR A PERIOD OF FIVE YEARS.
Permitfee's F -
Name:
Directions to property:< '
r DAVIE 'COUNTY HEALTH DEPARTMENT
IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION
IMPROVEMENT
PERMIT
r"
Subdivision Name c ti:=f.fir. ��i, r'
Section:" Lot:
Tax Office PIN:#
Road Name: rr..Zip:
V
**NOTE** This Improvement Permit DOES NOT authorize the construction or installation 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)
"'`NUlll:l;""' "l t11J YYKMl'1' lJ JUI3Jl;(:'1" •1"U Kr:VU(;A"17UN 1P' S1'1'l;
PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE
INSTALLING THE SYSTEM.
RESIDENTIAL SPECIFICATION: BUILDING TYPE / % /7 # BEDROOMS ,r # BATHS �--' # OCCUPANTS GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No
-/,!? (�- I c-7
LOT SIZE - TYPE WATER SUPPLY ) DESIGN WASTEWATER FLOW (GPD) ,_ C NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE/�,=' GAL. PUMP TANK GAL. TRENCH WIDTH 3 ROCK DEPTH LINEAR FT.
OTHER
Y
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT
"CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM
BETWEEN 8:30 - 9:30 A.M. OR 1:00 - 1:30 P.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (704) 634-8760.
OPERATION PERMIT
SYSTEM INgALLED BY: _
Ixe104 � ,
AUTHORIZATION NO. ` OPERATION PERMIT BY: DATE:
"THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE 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.
DCHD 05/96 (Revised)
4-
z` DAVIE COUNTY HEALTH DEPARTMENT
;:iIMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION
Permittee's . `
Name:
Directions to property: t
Subdivision Name
Section: ,�
Lot:
IMPROVEMENT
PERMIT Tax Office PIN:#
Road Name i s w r w ZIp:
**NOTE** This Improvement Permit DOES NOT authorize the construction or installation 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.
(Incompliance with Article 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
***NOTICE*** THIS PERMIT IS SUBJECT TO REVOCATION IF SITE
r PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE
INSTALLING THE SYSTEM.
RESIDENTIAL SPECIFICATION: BUILDING TYPE # BEDROOMS r # BATHS �� # OCCUPANTS GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLEISHIFr # SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZE s� TYPE WATER SUPPLY �'+ DESIGN WASTEWATER FLOW (GPD) - l ` ` NEW SITE l r' REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE�l`'�GAL. PUMP TANK GAL. TRENCH WIDTH —' °` ROCK DEPTH ,% / LINEAR FT...�
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT
• fir'
< 1�_�
1
i
**CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM
BETWEEN 8:30 - 9:30 A.M. OR 1:00 - 1:30 P.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (704) 634-8760.
OPERATION PERMIT \
SYSTEM IN.1TA ED BY:
07
A/
AUTHORIZATION NO. OPERATION PERMIT BY:A/v// DATE: /
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE 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.
DCHD 05/96 (Revised)
t
r
« APPLICATION FOR SITE EVALUATIONAMPROVEMENT PERMIT
Davie County Health Department
Environmental Health Section
P. O. Box 848
Mocksville, NC 27028
(704)634-8760
****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSED UNLESS
ALL THE REQUIRED INFORMATION IS PROVIDED.
1. Name to be Billed
�d �•' � Contact Person pp-qe41-
44 -Mailing Address U aQ� Home Phone ' -)w
City/State/Zip 6,00lleerna.,v. Business Phone '14# I;'6-6/
2. Name on Permit/ATC if Different than Above
Mailing Address _
3. Application For:
4. System to Serve:
5. If Residence:
OV Dishwasher
6. If Business/Other:
# Commodes _
If Foodservice:
❑ Site Evaluation O
❑ House OV/Mobile Home
City/State/Zip
C9' Improvement Permit & ATC
❑ Business ❑ Industry
# People # Bedrooms
❑ Garbage Disposal 0/Washing Machine ❑ Basement/Plumbing
7. Type of water supply:
Specify type
# Showers
# Seats
4/County/City
# Urinals
❑ Both
❑ Other
# Bathrooms d`
❑ Basement/No Plumbing
# People # Sinks
Estimated Water Usage (gallons per day)
❑ Well
# Water Coolers
8. Do you anticipate additions or expansions of the facility this system is intended to serve?
If yes, what type?
❑ Community
❑ Yes YNo
PROPERTY INFORMATION REQUIRED: *** IMPORTANT *** A PLAT OF THE PROPERTY MUST BE
SUBMITTED WITH THIS APPLICATION.
Property Dimensions: 1
Tax Office PIN: # ✓'� - ` / - ` ` 1
Property Address: Road Name j� / 1
City/Zip l � I 0 CR6 (%) I U"
1
1
If in Subdivision provide information, as follows: �Q
Name: 1
Section:
Lot #:
1
1
WRITE DIRECTIONS (from
Mocksville) TO PROPERTY:
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 suitability.
DATE + SIGNATURE I
Revised DCHD (06-96)
A DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section SECTION LOT �o b
Soil/Site Evaluation
APPLICANT'S NAME �� DATE EVALUATED
PROPOSED FACILITY 17 PROPERTY SIZE `
SUBDIVISION ROAD NAME
Water Supply: On -Site Well
Community
Evaluation By: Auger Boring Pit
Public G ---'l
Cut
FACTORS 1 2 3 4 5 6 7
Landscape position
Slope %
HORIZON I DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH 3 t"
Texture group
Consistence
Structure
Mineralogy r- ; '
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:
LONG-TERM ACCEPTANCE RATE:
REMARKS:
LEGEND
DCHD (01-90)
Landscape Position
EVALUATION BY:
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
■■
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Davie County, NC tTax Parcel Report Wednesday, January 4, 2017
Parcel Number:
NCPIN Number:
Account Number:
Listed Owner 1:
Mailing Address 1:
City:
State:
Zip Code:
Legal Description:
Assessed Acreage
Deed Date:
Deed Book / Page:
Plat Book:
Plat Page:
Building Value:
WAKNING: THIS IS NUT A SURVEY
No
Parcel Information
COOLEEMEE
M4010A0006 Township:
Mocksville
5726913991 Municipality:
SOUTH DAVIE
69870000 Census Tract:
37059-801
SPILLMAN CLARENCE Voting Precinct:
SOUTH CALAHALN
1949 JUNCTION ROAD Planning Jurisdiction:
Davie County
MOCKSVILLE Zoning Class:
DAVIE COUNTY R -A
NC Zoning Overlay:
DAVIE COUNTY CZOD
Land Value:
Total Assessed Value:
27028-0000 Voluntary Ag. District:
No
LOT 6 GRANT HEIGHTS 3.552 ac Fire Response District:
COOLEEMEE
3.55 Elementary School Zone:
COOLEEMEE
8/2011 Middle School Zone:
SOUTH DAVIE
008660454 Soil Types:
Gn132
10 Flood Zone:
371 Watershed Overlay:
DAVIE COUNTY
Outbuilding & Extra
Freatures Value:
Total Market Value:
I( All data is provided as Is without warranty or guarantee of any Idnd either expressed or Implied Including but not limited to the I
Davie County, implied wamnties of merchantability or fitness for a particular use. All users of Davie County s GIS website shag hold harmless the
Countyof Davie, North Carolina, Its agents, consultants, contractors or employees from any and all daims or causes of action due to
naC��� NC or arising out of the use or Inability to use the GIS data provided by this website.
**NOTE** This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior
to issuance of any Building Permits. This Form/Authorization Number should be presented to the Davie County Building Inspections
Office when applying for Building Permits.
(In compliance with Article l l of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
ENVIRONMENTAL HEAL SPECIALI
***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTIONIV
,�- - IS VALH) FOR A PERIOD OF FE YEARS.
ST DATE ISSUED
1499
49
AtORIZATION NO:
DAVIE
COUNTY HEALTH DEPARTMENT
ti
Environmental Health Section
PROPERTY INFORMATION
Perniittee's
P.O. Box 848
. ;
Name:/,' t
�."if��
r1 ►
Mocksville, NC 27028
Subdivision Name:
J ,
Phone #: 704-634-8760
;.r S --
Directions to property:%''
Section: /° Lot: i-
j
AUTHORIZATION FOR
WASTEWATER
Tax 9
SYSTEM CONSTRUCTION
Office PIN:#-�-
�4
Road Name: �lf CF_> / n Zip:
**NOTE** This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior
to issuance of any Building Permits. This Form/Authorization Number should be presented to the Davie County Building Inspections
Office when applying for Building Permits.
(In compliance with Article l l of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
ENVIRONMENTAL HEAL SPECIALI
***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTIONIV
,�- - IS VALH) FOR A PERIOD OF FE YEARS.
ST DATE ISSUED
91DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION
Name: +t"'/ a . i. ; ! ;,,ti ,) Subdivision Name ag'�fl 6fi�rP"�
Directions to property: f'. f 9' Section: Lot:
L IMPROVEMENT ,�,, ,, ,
PERMIT Tax Office PIN—:-# � � - `f r
Road Name: /d1I� Zip: �
**NOTE** This Improvement Permit DOES NOT authorize the construction or installation 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)
***NOTICE*** THIS PERMIT IS SUBJECT TO REVOCATION IF SITE
PLANS OR THE USE CHANGE. YOUR WASTEWATER
IE IN
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE
INSTALLING THE SYSTEM.
RESIDENTIAL SPECIFICATION: BUILDING TYPE/0 -� # BEDROOMS.:< # BATHS __:) # OCCUPANTS GARBAGE DISPOSAL: Yes or No
COMMERCIIALL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFr # SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZE ,:1 TYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD) NEW NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE D GAL. PUMP TANK GAL. TRENCH WIDTH .-� ROCK DEPTH /LINEAR Fr.-y'G61
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT
**CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM
BETWEEN 8:30 - 9:30 A.M. OR 1:00 - 1:30 P.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (704) 634-8760.
OPERATION PERMIT
S NSTALLEDD BY:
j l`e
-Y)o
AUTHORIZATION NO. / �" / / OPERATION PERMIT BY: `—'7 DATE:
**THE ISSUANCE OF THIS OPERATION PERMrr SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE
WITH ARTICLE 1 I 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.
DCHD 05/96 (Revised)
DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION
k
Permittee's
Name.
Directions to property:
Subdivision Name.
/ �'>°
Section:
IMPROVEMENT
PERMIT Tax Office PIN:# �;, 4, _ q1 -
Road Name:Zip: E%; �
**NOTE** This Improvement Permit DOES NOT authorize the construction or installation 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)
***NOTICE*** THIS PERMIT IS SUBJECT TO REVOCATION IF SITE
. J PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE
INSTALLING THE SYSTEM.
RESIDENTIAL SPECIFICATION: BUILDING TYPE # BEDROOMS ,— # BATHS # OCCUPANTS GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZE S TYPE WATER SUPPLY rt DESIGN WASTEWATER FLOW (GPD) ^ � y NEW SITE L- REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZEt C ' GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH LINEAR FT. J ,K6
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
**CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM
BETWEEN 8:30 - 9:30 A.M. OR 1:00 1:30 P.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (704) 634-8760.
OPERATION PERMIT
ST M4NSTALLE6BY:
Vo/1511
AUTHORIZATION NO. / OPERATION PERMIT BY: G4 ` DATE: /
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE 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.
DCHD 05/96 (Revised)
t
rhi
ST M4NSTALLE6BY:
Vo/1511
AUTHORIZATION NO. / OPERATION PERMIT BY: G4 ` DATE: /
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE 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.
DCHD 05/96 (Revised)
n APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
V V Davie County Health Department
Environmental Health Section h�
�1 P. O. Box 665 IAII
V Mocksville, NC 27028
1. Application/Permit Requested By S/"I L I � V U1 6,p
Mailing Address ✓ L�%N/i/c%T l0V D Home Phone % y t{'y 7
o7-' 72
/J DS V1 L[ C Al, Business Phone 7'040-)5 e%
2. Name on Permit if Different than Above Q 'fib Q4
3. Application for: UGeneral Evaluation E Septic Tank Installation Permit
4. System to Serve: ❑ House 13'—/ Mobile Home ❑ Place of Public Assembly
❑ Business ❑ Industry /❑ Other,/ ❑ Unknown
5. If house, mobile home: Subdivision ��- .✓T /Y�'/` iiY S Section _Z Lot #
❑ Basement/Plumbing
No. of People 22`� L1
No. of Bedrooms .7
Nn_ of Sathmnms
Dwelling Dimensions l 7 X ? v
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: hd Public ❑ Private
8. Property Dimensions Sewage Disposal Contractor
9. Do you anticipate additions/expansion of the facility this sytem is intended to serve?
If yes, what type?
❑ Basement/No Plumbing
"ashing Machine
❑ Dishwasher
❑ Garbage Disposal
❑ Yes ❑ No
❑ Community
t
*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: Jf
Vt7
P V'� �
,
,�� ;� ;veli.
PROPERTY INFORMATION
Tax Office PIN # �5 r/;/&- 7/
Road Name ZT041c r/aid RD
Box # (if available)
city LC-
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 his application
DATE SIGNATURE
CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY
MUST CHECK ONE: ❑ 1. 1 OWN the property. ❑ 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 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 said site's suitability for a ground absorption sewage treatment
and disposal system.
DATE SIGNATURE
OCHO (1193)
• DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation /I
NAME �/a h'1 {SIJ% DATE EVALUATED
ADDRESS PROPERTY SIZE
PROPOSED FACIILTY LOCATION OF SITE
Water Supply: On -Site Well _
Evaluation By: Auger Boring
Community
Pit
FACTORS 1 2 3 4
Landscape position L L
Sloe
HORIZON I DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH
Texture group
Consistence i
Structure S
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
Public
Cut
SITE CLASSIFICATION: - /T EVALUATED BY: Aa ZZ
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 ;lay loam, SIL -Silty loam CL -Clay loam SCL-Sandy clay loam
SC -Sandy clay SIC -Silty clay C -Clay
CONSISTENCE
Moist
VFR- V+--. -y 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
3C --Single grain M -Massive CR -Crumb GR -Granular ABK-Angular blocky
SBK-Subangular blocky PL -Platy PR -Prismatic
Mineralomy
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
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