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345 Serenity Hills Trail Lot 3+1 �► ' '' APPLICATION FOR SITE EVALUATIONAMPROVEMENT PERMIT & AT Davie County Health Department Environmental Health Section C� P.O. Box 848 ' / Mocksville, NC 27028 ! '0i D (704)634-8760 1p, ****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. 1. Name to be Billed W. Rod Hatcher Mailing Address 600 Alpine Road City/State/Zip Winston-Salem, NC 27104 2. Name on Permit/ATC if Different than Above Same as above Mailing Address Same as above Contact Person W. Rod Hatcher Home Phone 910/768-2144 Business Phone 910/761-1130 City/State/Zip 3. Application For: [ ] Site Evaluation [ ] Improvement Permit & ATC 4. System to Serve: [x] House [ ] Mobile Home [ ] Business [ ] Industry [ ] Other [x] Both 5. If Residence: # People 4 # Bedrooms 4 # Bathrooms 2.5 [x] Dishwasher [x] Garbage Disposal [x] Washing Machine [x] Basement/Plumbing [ ] Basement/No Plumbing 6. If Business/Other: Specify type # People #Sinks # Commodes # Showers # Urinals # Water Coolers If Foodservice: # Seats Estimated Water Usage (gallons per day) 7. Type of water supply: [ ] County/City [x ] Well [ ] Community 8. Do you anticipate additions or expansions of the facility this system is intended to serve? [ ] Yes [x] No If yes, what type? PROPERTY INFORMATION REQUIRED: *** IMPORTANT *** A PLAT OF THE PROPERTY MUST BE SUBMITTED WITH THIS APPLICATION. Property Dimensions: 13.49 acres ; WRITE DIRECTIONS (from Mocksville) TO PROPERTY: Tax Office PIN: # 5863 _ 56 _ 5838 I-40 east to 801 exit. Turn north to right Property Address: Road Name Sand Pit Road bn lright--on Yadkinville Road. Turn right City/Zip Davie County on Griffith Road, then left on Sand Pit If in Subdivision provide information, as follows: Road. Turn left in development. "-' a _l Name: _n� - - - Gn: River Bend Him#: 3 NArnf. _ n -PAP_ 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 �AViD MANES W1'200 NA-'[AERto ondup4ll(t�esting ro edures as necessary to determine the site suitability. DATE 7I / J q la SIGNATURE UA Revised DCHD (06-96) PRELIMINARY P"T FOR RIVER BEND KNOLLS TOWNSHIP WUNTY STATE DATE •y. �O OM-10-0J Woo M i� L. Roy Cotes Q7 hj 119 Depot Street JOB NO. ^ Mu%;ksville, NC 27028 MAP N• 411-2607V NiP yA v= �o a 2 NIP .o to rn W 010 W 0u ��, IN _2 Lri �t- to cp � N o 139491 /NIP co Z oo in � V a C o 90 !IIP . • , 258.7 2 338.21 Point N I 2 U��w point Point 103.9 61 " 159.76' Poll 035,50,114 N 01 040'30"W N 13 Total 263.52' w DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation NAME �/LF%� DATE EVALUATED ADDRESS PROPERTY SIZE PROPOSED FACIILTY /`�� LOCATION OF SITE Water Supply: On -Site Welly--- _ Community Public Evaluation By: Auger Boring rf 1Qit Cut FACTORS 1 4 Landscape position Slope Z HORIZON I DEPTH 29<< <i Texture group Consistence Structure Mineralogy HORIZON II DEPTH Texture group � Consistence Structure Whk 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:y� EVALUATED BY: LONG-TERM ACCEPTANCE ATE: REMARKS: &V G W / a DCHD(01-901 Landscape Position OTHER(S) PRESENT: ,)A,n 44 i .02 .w 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 T i _ exture 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 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 • Davie County Aealtfr Department - and Horne AealtFr ffyency 210 HOSPITAL STREET I P.O. BOX 665 MOCKSVILLE. N.C. 27028 PHONE: (704) 634-5985 July 22, 1996 Rod Hatcher 600 Alpine Road Winston-Salem, NC 27104 Re: Site Evaluation Sand Pit Rd. Tax PIN: #k5863-56-5838 Dear Mr. Hatcher: As requested, a representative from this office visited the aforementioned site on July 18, 1996. Based upon 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 over -sized modified on site sewage disposal system. If you have any questions, please feel free to contact this office. Sincerely, Robert B. Hall, Jr., R.S. i Environmental Health Section t RBH/wd Enclosure(s) S' .