172 Shady Grove Lane Lot 6r AUtfRQI4SRIDATION NO 1 6 % 6 ' DAVIE C LINTY HEALTH DEPARTMENT /
Environmental Health Section PROPERTY INFORMATION
Permittee's P.O. Box 848
Name 4C �`� Mocksville; NC 27028 Subdivision Name:
Phone # 336-751-8760.
Directions to property: i��/�/(/ ` . " Section: Lot:,
' ��/,,rel / AUTHORIZATION FOR
N SYSTEM CONSTRUCTION., Tax Office PIN: -
VIM, n
Road Name: Zip: 7006
**NOTE*".This' Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior
to issuance of anyBuildingP.ennits. This Form/Authorization Number should be presented to the Davie County Building Inspections
Office when applying for Building Permits.
(In compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems; Section..1900Sewage Treatment and Disposal Systems)
***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH SPECIALIST ,DATE ISSUED - -
APPLICATION FOR SITE EVAWAIION/jMPR0VEMhM PERMIT & � T R 0 T D
Davie County Health Department
Environmenfa/Hea/thSection i i=-5 OCT
P.O. Box 848/210 Hospital Street
Moakaville, HC 27028
(336) 751-8760 ENVIRONMENTA,I,6HHEAUH
***gPOgTAlM*** THIS APPLICATION CANNOT BE PROCESSED OHLRSS ALL THE REQUIRED
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
i
A. name to be ailled'*Ldd/ - // ;1fW0/C A/S7"2u6r/-A)20(n contact nerson ��DS'r<-,v .,J-_
Hailing Address '7/7AKFLA/flu ')&,a% some Vhone 3310-9�I�-a6/S
City/State/alp jj G�SUiLLe /r/l; a7o
Business Phone
2. Name on peffit/ATC If Different than Above
Halling Address City/state/alp
3. ApPlication For: Site Evaluation
4. Systm to service: )k House O Mobile Home
s. If Residence:
XDishwasher
/'People 3
Improvement Permit/ATC O Both
0 Business O Industry 0 other
/ Bedrooms —_ ! Bathrooms a'S'
D Garbage Disposal washing Hachlne
6. If Business/Industry/other: Specify type
i Ccsmodea i Showers
D Basement/Plumbing m Baste t/bvo Plumbing
f People / sinks
4 Urinals 4 water Coolers
IF FOODSERVICE: % Seats Estimated Rater Usage (gallons
Per Say)
7. Type of Hater supply: ,,County/City 0 Well
0 Community
e. Do you anticipate additions or expansions of the facility this system is intended to serve! 0 Yes ANo
H yes, what type!
"**IMPORTANT"' CLIENTS MUSTCO"PLETETRE REQUIRED PROPERTY INFORMATION REQUESTED
BELOW. Either a PWT or SITE PLAN MUST BE SUBMITTED by the client with THIS APPLICATION.
pwl Vac epe- 0.?53.�3
Property Dimensions: a 3. 9i3X /li�7a X x'902 x WRITE DIRECTIONS (from Mocksvllle) to PROPERTY:
Tax Office PIN: 9— ys—/�fD7/n�OD/P> ?yD h, RO/ 6'M17 y -/a ei�rt� 111le FCTA-'D
Properly Address: Road Name _/r%2 c��i � C9l�LljNC 11f7 Oaf/J�Ci rcbyg lave
City/Zip Aa LAW r16 4,4L.
If in a Subdivision provide information, as follows:
Name:
aliV/P.
Section:
Block:
LGN
Date Property !lagged: le -1-9 V
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 aR charges incurred from
this WHcadom I, hereby, give consent to the Authorized Representative of the Davie County Health Department
to enter upon above described property located fa Davie County and owned by
to conduct all testing procedures as necessary to determine the site suitability.
DATE _ /O —S— 91Y SIGNATURE
THIS AREA MAY BE USED FOR DRAWING YOUR SITE LAN (Include all of the following: Existingand proposed
property lines and dimensions, structures, setbacks, and septic locations).
Revised DCHD (07/98)
gt a a, 9.3
Account No. A,
Invoice No. Z S
NAME
ADDRESS
PROPOSED FACIILTY
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
DATE EVALUATED z2LA
PROPERTY SIZEl�c
LOCATION OF SITE
Water Supply: On -Site Well Community Public (�
Evaluation By: Auger Boring Pit - - /// Cut -
FACTORS
1
2 3 4
Landscape position
Slope Z
HORIZON I DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH
Texture group
<t_
6 -
Consistence 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: .'EVALUATED BY: Z/
LONG-TERM ACCEPTANCE RATE: t 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 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 -Nonplastic 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 wateror 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 (01-901