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124 Sumter Road Lot 5Davie County, NC Tax Parcel Report Tuesday. November 15. 2016 WARNING: THIS 1S NOT A SURVEY Parcel Information Parcel Number: F3010A0005 Township: Clarksville NCPIN Number: 5811723398 Municipality: Account Number: 82530153 Census Tract: 37059-801 Listed Owner 1: POWERS CELIA C Voting Precinct: CLARKSVILLE Mailing Address 1: 124 SUMTER ROAD Planning Jurisdiction: Davie County City: MOCKSVILLE Zoning Class: DAVIE COUNTY R -A State: NC Zoning Overlay: Zip Code: 27028-0000 Voluntary Ag. District: Legal Description: LOT 5 CHARLESTOWNE GRANT Fire Response District: Assessed Acreage: 1.48 Elementary School Zone: Deed Date: 9/2008 Middle School Zone: Deed Book 1 Page: 007720111 Soil Types: Plat Book: 0009 Flood Zone: Plat Page: 124 Watershed Overlay: Building Value: 217750.00 Outbuilding 8n Extra Freatures Value: Land Value: 36400.00 Total Market Value: Total Assessed Value: 258650.00 No WILLIAM R. DAVIE WILLIAM R DAVIE NORTH DAVIE MnC2,MnB2 DAVIE COUNTY 4500.00 258650.00 161 Davie County, 7�TAll 1� C data is provided as is without warranty or guarantee of any Idnd either expressed or Implied Including but not limited to the Implied warrantles of merchantability or fitness for a particular use. All users of Davie County's GIS website shall hold harmless the County or Davie, North Carolina, Its agents, consultands, contractors or employees tram any and all claims or causes of action due to or ung out of the use or inab ft to use the GIS data provided by this websfte. DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boa 848/210 Hospital Street ry) ` Mocksville, NC 27028 (336)751-8760 Account #: 990004066 Billed To: B. Square Builders, Inc. Reference Name: ATC Number: 4476 Tax PIN/EH #: 5811-72-3398 Subdivision Info: Charleston Grant Lot # 5 Location/Address: Sumter Road -27028 I* AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION **NOTE** 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 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems). THIS AUTHORIZATION FOR WASTEWATE TI IS ALID FOR A PERIOD OF JIVE YEARS. Environmental Health Specialist's Signature: Date: 29 zy z� z� CERTIFICATE OF COMPLETION **NOTE** The issuance of this C of C letion shall indicate the system described on Improvement/Operation Permit has been installed in 1% th icle 11 of G.S. Chapter 130A, Section .1900 "Sewage Treatment and Disposal Systems," but n WA taken as a guarantee that the system will function satisfactorily for any given period of time. �gOAF Septic System Installed By: Environmental Health Specialist's Signature: DCHD 05/99 (Revised) 141 I j,-7Z)C)-7 ,; • • DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boz 848/210 Hospital Street �Q Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account M 990004066 Tax PIN/EH #: 5811-72-3398 Billed To: B. Square Builders, Inc. Subdivision Info: Charleston Grant Lot # 5 Reference Name: Location/Address: Sumter Road -27028 Proposed Facility Residence Property Size: 1.5 acres `'ATC Number: 4476 **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'Speci&ation: Building Type ' #People #Bedrooms -#Baths " Dishwasher: El Garbage Disposal: ❑ Washing Machine: ❑ Basement w/Plumbing: l2ro"_Basement/No Plumbing: ❑ Commercial Specification: Facility Type__,__ #People #People/Shift rr 11##S�Se,,..ats Industrial Waste: ❑ Lot Size Type Water Supply'//���r0'JIVDesign Wastewater Flow (GPD) ` 20 Site: New Repair ❑ :.System Specifications; Tank Size g ` y -AL Pump Tank Other: Required Site Modifications/Conditions: �t GAL.' Trench Width , 2, 1e;: Rock.pepth • N A. Linear"Ft. V, l /-rl 1 �1 CTi7 � �.,1 r►�.1 K,o k6�Pl��' IMPROVEMENT/OPERATION PERMIT LAYOUT - APPROVED EFFLUENT FILTER. RISER(S) IF 6 " BELOW FINISHED GRADE. ****NOTICE: Contact a representative of the Davie County Health Department for final inspection of this system between 8:30 a.m. to 9:30 a.m. or 1:00 p.m. to 1:30 p.m. on the day of installation. Telephone # is (336)751-8760.**** v `S $nviro mental -Health Specialist's ture.: : D y � DC 05/99 (Revised) DAVIE COUNTY HEALTH DEPARTMENT • ,�t Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990004066 Tax PIN/EH #: 5811-72-3398 Billed To: B. Square Builders, Inc. Subdivision Info: Charleston Grant Lot # 5 Reference Name: Location/Address: Sumter Road -27028 Proposed Facility: Residence Property Size: 1.5 acres **NOTE * This improvem6ent/Operation Permit DOES NOT authorize the construction 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). 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 f UX&E #People 4 #BedroomN7 s ' #Baths Z Dishwasher: ❑ Garbage Disposal: ❑ Washing Machine: ❑ Basement w/Plumbing: 2TOO' Basement/No Plumbing: ❑ Commercial Specification: Facility Type// -- - #People #People/Shift #Seats Industrial Waste: (te❑ Lot Size Type Water Supply a w Design Wastewater Flow (GPD) � Site: New Repair ❑ System Specifications: Tank Size GAL. Pump Tank GAL. Trench Width :�V► Rock Depth Q Linear Ft. �Jv, Other: �l' 1i) 2��j IZf~�I�Gfty�.9 S T I .3 �D1ST>�ilal)r�or7 � Required Site Modifications/Conditions: �►.�sidLt peJ LQ�•ii0t7� �►c'f 5� r -FP � ��T, �V AFF IMPROVEMENT/OPERATION PERMIT LAYOUT - APPROVED EFFLUENT FILTER RISER(S) IF 6 " BELOW FINISHED GRADE./****NOTICE: Contact a representative of the Davie County Health Department for final inspection Of this system between 8:3 a.m. to 9:30 a.m. or 1:00 p.m. to 1:30 p.m. on the day of installation. Telephone # is (336)751-8760.** * I r."W 1..1.Ja----------- — Environmental Health Specialist's )L^• 0 DCHD 05/99 (Revised) pwx 1 Pl CIA 1,so� –: 7--,L4 ti Rat L,sts id oPbt Date: 84 lot 174 LOT #4 AREA= 1-8,37 ACRES '3 -7 N c . n r 11 �� Page I of I ks� )6l4;, -AT �4's \0��'Lbi LtKr-- N56tb( e� file -,-','C:',.DOCU-N4F— Ulianhur:ALOCALS-1 Uemp\EJSD1 YDH.btm &;2W2006 Davie Counh,- GIS Online Legend Address P.Ants SAv4 4 1. rr ................. JAI Alm WNW ks� )6l4;, -AT �4's \0��'Lbi LtKr-- N56tb( e� file -,-','C:',.DOCU-N4F— Ulianhur:ALOCALS-1 Uemp\EJSD1 YDH.btm &;2W2006 :.1 APPLICATION FOR SITE EVALUATION/IMPROVEMENT PER T .& talTc Davie County HealthDepartment j Environmental Health Section P.O. Box 848/210 Hospital Street M Mocksville, NC 27028 H (336)751-8760/ Fax (336)751-8786 Application For: ❑ Site Evaluation/Improvement Permit authorization To Construct(ATC) ❑ Both ***IMPORTAN*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. APPLICANT RM T ON Name to be Billed ' Contact Person Billing Address C L' Home Phone ?�?�G ?, ( , OQ O City/State/ZIP "3j _ 0: �o,- C20 (, U5 (9 Name on Permit/ATC if Different than Above IC--) t�Q (kkRi L Mailing Address 415'r1EIkIC'E N-+Z\V E City/State/ZiD (� PROPERTY INFORMATION NOTE: A survey plat or site plan must accompany this application. (Permit is vali for 60 months with site plan, no expiration with complete plat.) Street Address jU` '�' City Nf16Ck5yt �'ETax PIN# Subdivision Name LEST Sec�Lot# �� Lot Size Directions To Site: Date House/Facility Corners ,Flagged O z' 0 If the answer to any of the following questions is "yes", supportin Are there any existing wastewater systems on the site? Does the site contain jurisdictional wetlands? Are there any easements or right-of-ways on the site? Is the site subject to approval by another public agency? Will wastewater othet than domestic sewage be generate documentation}�ust be attached. ❑Yes i Vo ❑ Yes >eNo ❑Yes •01�o ❑Yes B<o ? ❑YestIGo IF RESIDENCg FILL OUT THE BOX BE ONV # People # Bedrooms # Bathrooms Garden Tub/Whirlpool ❑Yes 9N-6 Basement: �'es ❑No Basement Plum ing: 9 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: 915onventional ❑Accepted ❑Innovative ❑Alternative ❑Other y Water Supply e: �LCounty/City Water ❑New Well El Existing Well Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes E40 If yes, what type? Well 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 understand that I am responsible for all charges incurred from this application. I hereby grant right of entry to the Authorized Representative of the Davie County Health Department to conduct necessary i spections to determine compliance with applicable laws and rules on the above described property located in Davie Cbunty and oned 4� lz i A, 0 K d RcLkh IK E Sign,given dyes ❑No Revised 2/06 Site Revisit Charge Date(s): Client Notification Date: EHS: Account # Invoice # 10/11/2005 10:42 FAX 19736582707_ — PARSIPPANY 8 10%33a davie coUnty envheal'Ch 338 751 8786 APPUCA71ON roR Erm EYAWAYION%IIijPIlO'rl:niE r nmiu & AYc Davie County Health Dept:(inent �itvlionmetrtalKeaftlt 5rltUon P.O. 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Iunilmst.md litstniW.Vennil(6) issucd hcrcaflcr. arc subjcc( to owperAou ar ievacatluu, frthe slteplaaa crintended vsa change, or U (heinformation submitted in (Illsapplic+Uva is falsified or chanted. r,, also) prfrlarstarlq' oat rima rarponsiorejri rflu enurgasbrcurreilJFam r/ris apprleAllon, I, uerelry, gave eousemr to aicAuuiorizcdRcprwcdtali-•e of Lite Aatie County33callli Departnunt to enter tipgn above described proprrtylurAlcd its Davie County and owned by _q-, L.L, Q_012DUTA1) to eot(Jucl all (UN (III procedures as necessary to dcicrmincihcsilozuitability. _ Zig �sl�Naxlmla tt� TIILSAREAll?AYULUSIM AMR1RA V1NGYDVRSI1'EJ.'x.AN(Ic:IadoallOfthefollo�rin': isfingmid proposcd property lincsandtlimcnsiot:s, slim(tures, actbactts, apdseptirlu=ficis). 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Jcs>�S 1 A13A.. 1237 xcss Da 6..er 9524 . reocso.. v 1+1- .+-i 2� t�s•�t9'Li iW � rw._�...y ..,-:..a.�.e.. Y tr+ua If �_ ..moa w..+w1..o.s. lw wy a ...ms } $ L•25Z1 11 �.a,d r'�"'i. a'}r�^ . CI 1\7 71 rr.�`�".�,. � rd.��..r.� w.c.e .� . .2N G • -• *.7 ,lura a e<K G4RQ4'. LOT �6 - AfFjr' I2r. Jcs>�S 1 cfl Da 6..er 9524 . reocso.. v 1+1- .+-i 2� t�s•�t9'Li iW � rw._�...y ..,-:..a.�.e.. GA% G..a Q7 �_ ..moa w..+w1..o.s. lw wy a ...ms } $ L•25Z1 11 �.a,d r'�"'i. a'}r�^ . CI 1\7 71 rr.�`�".�,. � rd.��..r.� w.c.e .� . 01-1 $1.0 11 W r 7Cm nit AI.O .25�aY' .'5.00 1611 •i]e G .J ��1�I,..y.��0.• rt v 'ti�Y�3��('f�(�• 1�w:. Ira � DO l�.y 'O LOT 92 -7 1:= + N$1- 1.162 ACFMS J'ratd mm D so» 4.vcw �>m U11 mm /� f Q1r8' .•... m- tis. .Ty lot cCN �l? 07 P4B ZSZ f L=a to rbj3 fn Lbi � ir.d'71 D ur .Tires• 7 1 iSRI i0 -0C BrA i•J0.4 � b t< YOi to r�iQ 50 WmS, ,,,Jt term us�f of Plt�xi Dr.:a [o. t[d � cxl fVl i11ew 111.(2 cvrlyrs LOT 19 ' °°°., �-T. �: G. -...:.. .�_ AM- 1-it8 AryIS. 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ISI 189 =TS: 11 - ltG' T'UT lmy SVRT[kim� COl 127 «r awrl moo w?ax1L tC 2n7D Ca') nt-5dsm ID3 Al 0 1w i � O SCALE IN rCET O lV O F—+ .A O•I � 1 .+ GA% G..a Q7 vAec oesl 1,551, 1AC1 nuo co co 00 CI }5471• ]IOU C] q 01-1 $1.0 11 W r 7Cm nit AI.O .25�aY' .'5.00 1611 •i]e G C. tggg 5147 list •I.1] amu' DO m Cl CA ]1151 Ind 1 � YS'IT ]COO -ft JS." J21(•OY rrm IG 16St -7 1:= o C" J'ratd mm D so» 4.vcw �>m U11 mm /� C11 Q1r8' .•... m- tis. .Ty lot cCN xzcs 1511. t)93-4 25-110 L=a to rbj3 fn Lbi � ir.d'71 D ur .Tires• 7 1 iSRI i0 -0C .y i•J0.4 � b t< YOi to r�iQ 50 term us�f of Plt�xi Dr.:a [o. t[d � A .titin M to a d fVl i11ew 111.(2 cvrlyrs ta, K=L w - -t .ri:. 2mv .�_ URLW sk wcK IMS rm.c - J C= UX MAP W. r-% ItNCM 112 CHARLES TO TFNI XDW6RD_ L. A?RRELL, u rutIDx >m+a so CLARKSVUE TOWNSH DAVIT COUNTY, NORTH CA SCFI6RBFP. ISI 189 =TS: 11 - ltG' T'UT lmy SVRT[kim� COl 127 «r awrl moo w?ax1L tC 2n7D Ca') nt-5dsm ID3 Al 0 1w i � O SCALE IN rCET O lV O F—+ .A DC / t1gi1M l•Ar silt . Jqa= SL 41 - rad A— - 27-V.5 / G wz Is t.. pt w g D.:. c— R / to rbj3 fn Lbi � ir.d'71 D i•J0.4 � b t< YOi to r�iQ 50 us�f of Plt�xi Dr.:a [o. t[d � A .titin M to a d UX MAP W. r-% ItNCM 112 CHARLES TO TFNI XDW6RD_ L. A?RRELL, u rutIDx >m+a so CLARKSVUE TOWNSH DAVIT COUNTY, NORTH CA SCFI6RBFP. ISI 189 =TS: 11 - ltG' T'UT lmy SVRT[kim� COl 127 «r awrl moo w?ax1L tC 2n7D Ca') nt-5dsm ID3 Al 0 1w i � O SCALE IN rCET O lV O F—+ .A Sep 2.1 015 1.1:314. davie count8 envhealth 336 751 8786 p.2 DAVIE COUNTY HEALTH )EPARTMENT Environmental Health: Section SECTION LoT� SoiUSite Evaluat -on APPLICANT'S NAME DATE EVALUATED PROPOSED FACIL,IIT,Y� ('S PROPERTYSIZE SUBDIVISION K(L�1>rY�f�Qil ROAD NAME 1A)4C1/)J9 99 Water Supply: On -Site Well _ Community Public ✓' Evaluation By: Auger Baring_ Pit Cut FACTORS 1 2 3 4 S 6 7 Landscape position L t_ Sloe % G y HORIZON I DEPTH Texture group Ci_ Consistence Structure 5 g Mineralogy 1: 1 HORIZON H DEPTH ,:) - • -7 - Sd Texture group Consistence S15 Structure Mineralogy HORIZON III DEPTH to -g 7 -Le Texture u Consistence SS Cr Structure Mineralogy ` L / . ; HORIZON IV DEPTH - i. I. ��f 1CF 3 Texture group Consistence Structure . Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION t LONG-TERM ACCEPTANCE RATE I1, SITE CLASSIFICATION: lis 1: VALUATION BY: _ c)Z:iCF -ti LONGTERM ACCEPTANCE RATE: Q 35 t tTHER(S) PRESENT: REMARKS: A -r Yr I GaALT.z� LEGEND L soap _ posi ion R - Ridge S - Shoulder L - Linear slope FS - Foot slope N -Nose slope CC - Concave slope C"V - Convex slope T - Terrace FP - Flood plain H - Head slope Texturt9 S - Sand LS - Loamy sand SL - Sandy loam L - Lown Sl - Silt SICL - Silty clay loam SIL - Silty loam CL - Clay loan SCL - Sandy clay loam SC - Sandy clay SIC 411ty clay C - Clay CONSI.STENCF. Moist VFR - Very friable FR - Friable FI - Firm VFI - Ver;- firm EFI - Extremely firm 3W NS. Non stiel<y SS - Slightly sticky S - Sticky VS -Very Sticky NP - Non plastic SP - Slightly plastic P - Plastic VP - Very plastic Rtntctu e SC - Single grain M - Massive CR - Crumb OR - Grf•iular ABK -Angular blocky SBK - Subangular blocky PL - Platy PR - Prismatic Mineralogy 1:1, 2:1, Mixed Naim Horizon depth - In iuehms Depth of fill - In inches Restrictive horizon - Thickness and inches from land surface Saprolite - S(suitable), U(uttsultable) Soil wetness - Inches froin I. -Ind surface to free water or inches from Iand surface to soil colors with chroma 2 or less Classification - S(suitablu), PS(provisionally suitable), U(unsultt.5le) LTAR - Long-term accepta:ee rate - gal/day/ft2 DCHD(01-90) HOMO J dod VUI10M MEd WO 966 9££ YV9 69:II Qd61 90OZ/IZ/60 818336 0 d . s po m Dai,Ijk- er Norli Carolina Click on the Map to: d Zoomin U ZoomOut a Recenter Map Q Identify: Parcels Zoom Factor. Q Radius Search (feet) NW 1 WIT s NF Parcel Data Find Adjoining Parcels • County ID: F3010A0005 • Account Number.10848000 • PIN:5811723398 • Legal 1:LOT 5 CHARLESTOWNE GRANT • Owner Name: BROWN JILL C • OwneNAddress 1: BROWN JILL C • Owner/Address 2: • OwneNAddress 3: PO BOX 157 • City, State Z .. MOCKSVILLE ,NC 27028 - 0000 Co— Land Value: $28,000.00 ----------------- • Building Value: $0.00 • Land Unit/Type: F3010A0005 J LT • De e: 00320 / 0436 • Deed Date: 1999/11/29 • Sales Price: $27,000.00 • 000124 000124 RD • County Zoning. R -A • Census Code: • City Code: . • Fire Dishict. WILLIAM R. DAVIE • Flood Zone: ZONE X • Flood Community. -370308 • Flood Panel: 0025 C • Flood Map Date: 12-17-1993 RSM Map L; Draw select Census Tra City Bound [j County Zor Multi Syl [] E911 Fire D [] Flood Pane [] Flood Zone [-1 Parcels [] School Dist Multi Syl ❑ Soils Town Zonk [] Townships Multi Syi [� Voting Pre( Driveways [] Rail Lines [] Street Cent US/NC Higl Multi Syi U N [] Aerial Phot 'hysical [] Creeks and [] E911 Addr( [] Fire Depart [] Schools MW I MAP Ci This map is prep, inventory of real 1 within this jurisdic compiled from rei plats, and other F and data. Users c hereby notified th D"IE COUNTY HEALTH DEPARTMENT _ Environmental Health Section Soil/ Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990003771 Tax PIN/EH #: 5811-72-3398 . Billed To: Linda O'Rourke Subdivision Info: Charleston Grant Lot # 05 Reference Name: Location/Address: Wagner Road -270 Proposed Facility: Residence Property Size: see map Date Evaluated: Water Supply: Evaluation By: On -Site Well Community Auger Boring Pit Public Cut FACTORS 1 2 3 4 5 6 7 Landscape position 1i Sloe % ?fl HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON H DEPTH Texture group Consistence Structure a 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: LONG-TERM ACCEPTANCE RATE: REMARKS: LEGEND EVALUATION BY: OTHER(S) PRESENT: Lan&qcape 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 Moist VFR - Very friable FR - Friable FI - Firm VFI - Very firm EFI - Extremely firm 3y -d 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 LYQtes ' 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 05105 (Revised) APPUCAMON FOR SITE EVAU ATION/IMPROVEMENT PERMIT & ATC Davie County Health Deparbnent Emrir0nmes7tal Health Section P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 ***n-IPCRTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 1. Name to be Billed y/��c% C_OL �EC�. Contact Person l�iJr4f/J �GQ2E(i� Mailing Address �1'jZ /TLED6E erg Home Phone `�f�/yZ city/state/ZIPMOGK5d/LLL�.dc- Z%OTia�/ Business Phone 4qz 2. Name on Permit/ASC if Different than Above Mailing Address City/State/Zip 3. Application For: X Site Evaluation ❑ Improvement Permit/ATC ❑ Both 4. System to service: A House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other 5. If Residence: # People # Bedrooms # Bathrooms -�---- 11 Dishwasher 11 Garbage Disposal U Washing Machine 11 Basement/Plumbing 11 Basement/No Plumbing 6. If Business/Industry/other: Specify type # Commodes # Showers # Urinals # People # Sinks # Hater Coolers IF FOODSERVICE: 1) Seats Estimated Water Usage (gallons per day) 7. Type of water supply: County/City 11 Well U Community 9. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes 'KNo If yes, what type? ***IMPORTANT*** CLIENTS AIUST C0.41PLETETHE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN AIUST BESUBbIITTED by the client with THIS APPLICATION. Property Dimensions: Z • ?iAe - / n / RITE DIRECTIONS (from Mocksville) to PROPERTY: Tax Office PIN: # gl!a�' Property Address: Road Name WACWi:k'1 D M/� LeET 0".J L/BE�TN /'o / City/Zip �O C S ✓l L [.E Z %v 7.t� If in a Subdivision provide information, as follows: Name: — �}1441.t.Te�°"JT Y Section: Block: Lot: '23o This is to certify that the information provided is correct to the best of my knowledge. I understand that a7nypermit(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. 1, hereby, give consent to the Authorized Representative of the DfvieCount 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 / / d SIGNATURE �-' 0 ..�- . r DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section SECTION LOT_ Soil/Site Evaluation APPLICANT'S NAME IAJ LJU6U­ PROPOSED FACILITYVsli SUBDIVISION Water Supply: On -Site Well Community. Evaluation By: Auger Boring Pit DATE EVALUATED`! / mhe loi-AA) PROPERTY SIZE ICD * ROAD NAME Public Cut FACTORS 1 2I 3 4 5 6 7 Landscape position16 Slope % 6'HORIZON I DEPTH Texture group C Consistence 55 Structure Mineralogy HORIZON II DEPTH 7 Texture group Consistence S Structure Mineralogyj HORIZON III DEPTH t -3(gic-%+5�0 Texture groupG .} Consistence r ;se SS SI f:r Structure I� Mineralogy HORIZON IV DEPTH + 3 L ctYF 310 - — Z Texture groupS Consistence Structure $ Mineralogy' SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: PS LONG-TERM ACCEPTANCE RATE- 6 EVALUATION BY: 'A 14 ' 4q9 OTHER(S) PRESENT: REMARKS: Af r i2l)AMZ, 96CY- t „ DIA,,, • LEGEND Landscaue 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) ■EME■ ■MME■ ■EN■■ ■■NE■ ■E■■■ ■■■M■ ■E■E■ NOOSE ■E■■■ ■■■E■ MMEMENAME ■■■■MM■■■ ■■■■i■■■■ ■■MUM■■■■ ■■r■■■■■■ AMEMMEM ■■■E■■M■■ MEMO■■■■■ ■■■E■E■■■ ■MNEME■■■ ■■■■EE■■■ ■■ENE■■E■ ■E■■■■■■■ M■■■■■■■■ NM■■■■■■■ MOMMEMEME ■EN■■■■■■ ■■►EEE■■■ ■■■R■■■■■ ■E■■ NEON ■E■■ ■■M■ ■■O■ ■■M■ ■■■EM■ ■O■ME■ ■ENN■■ MEN ■ ■■■■w MMmMM■ ■■■EM►EE■■■M■ ■MEMEMOMM■■E■ `n■■■■■■■MM■■ ■u■■■E■■■■■■■ ■■■■■■■■■■■■■ ■■■■■E■E■E■■■ U■■■■■■n■■■ ■■EMME ■■■ ■■■ECOMM■O■■■ ■■■E■PHE■■■■■ ■■MMUME■■■■■■ ■■■■MMEM■■■M■ ■■E■IVEMME■M■M ■■■■UME■■■E■■ ■EMERIM■■ ■■■ ■■■■11■■■ M■■ ■■■■WOMMENEE■ ■■EMIT "NONE A■■ON■ ■M■■E■ ■■EM■■ ■ENN■■ ■■EOM■ ■E■■■■ ■■■N■■ ■EM■■■ ■■■MN■ ■ENNEN ■■■FAME ■■EMEC! ■■I/MM■ ■NII■■■ ME on ■E■■■ ■■■E■ SEMEN ■E■E■ ■EN■■ ■EN■■ DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section PO Box 848/210 Hospital Street Mocksville, NC 27028 Phone: (336)751-8760 /Fax: (336)751-8786 October 17, 2005 Linda O'Rourke 24 Summit Ave. Cedar Knolls, NJ 07927 Re: Site Evaluation- Charlestowne Grant/Lot # 5 Tax PIN#: 5811723398 Dear Client(s): As requested, a representative from this office revisited the above site October 17, 2005 to consider the tract for a four-bedroom residence. Based on the information provided on the Application for Site Evaluation and after the evaluation was completed, the site was found to be provisionally suitable for the installation of an on-site sewage disposal system. House location, size and other design criteria may necessitate the use of an alternative or innovative system. System design will be determined at the time an Improvement Permit/Authorization to Construct is applied for and issued. Before a representative of this office will revisit the site to issue an Improvement Permit/Authorization to Construct, the appropriate application must be completed and submitted to this office. The location of the facility the system is to serve must be staked off. Enc(s) If you have any questions, feel free to contact this office at 751-8760. Sincerely, Jeff G. Beauchamp, R.S. Environmental Health Section