416 Sheffield Farms Trail Lot 8toissuancc of any Building'Pennits. This Form/Author
Office when applying for Building Nrmiis
(ln compliance with Article 11 of SsChapter 130A; Wastewater
SNVI O % ALT.HSP CI T , DATE�1 SUE
r r APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & AT D LS L5 Q
Davie County Health Department
Environmental Health Section
P.O. Box 848/210 Hospital Street 2
Mockaville, NC 27028
(336) 751-8760 ENVI DAVM,TUNTNY�TH
***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 ,E�`�� NN-L�NoT�Q' -,n 0 xe contact Person /(�A�/1n, : e (�� qde r rl
Mailing Address �/ / CO ,e /1/4 / Z z� C X I% Home Phone 7 g
city/state/ZIP aG�S [// L.L. Lf �✓ G A t% 0') JBusiness Phone %(� / A � G / Q % iy 6,0y/
2. Namon Permit/ATC if Different than Above /
e
Mailing Address - City/State/Zip
3. Application For: ❑ Site Evaluation ❑ Improvement Permit/ATC 9T30th
4. System to service: ❑ House P Mobile Home ❑ Business ❑ Industry ❑ Other
S. If Residence: # People _q- # Bedrooms ? # Bathrooms /
0"Dishwasher D Garbage Disposal 1) Washing Machine ❑ Basement/Plumbing ❑ Basement/No Plumbing
6. If Business/Industry/Other: Specify type # People # Sims
# Commodes # Showers # Urinals # Water Coolers
IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day)
7. Type of Water supply: ❑ County/City 0/well ❑ Community
a. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes ❑ No
If yes, what type?
***IMPORTANT***CLIENTS MUSTCOMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED
BELOW. 'Either a PLAT or SITE PLAN MUST BE SUBAHITED by the client with THIS APPLICATION.
Property Dimensions(4f; ITE 6LA4 p / WRDIRECTIONS (from M1ocksviCe) to PROOERTY:
Tax Office PIN: # ' 16 9 1 O Z K_!�_1 7 3
Property Address: Roam Name�P}js T
Cih//Zip /%%OC&S✓/AL Lf '�% 0.2 —tl _�n4h
If in a Subdivision provide information, as follows: S _6L
Name: A;9 ea _Z5
Section: Block: Lot: Date Property Flagged: J - Z 9 - 9e
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 incurredfrom
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.
2
DATET�� SIGNATURETHIS 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).
it
Account No. i a
Revised DCHD (07/98) Invoice No.
Account No. i a
Revised DCHD (07/98) Invoice No.
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54'50"1y
QiuV• 94.89' r ,
rip 213.75' S 58°15'15"w
N 87°44'20"W 17p.37'
:FACTORS,
1
2.
3 _4 5 6 7.
Landscape position
L
`,
L
Slope %
HORIZON I DEPTH
O L
O -8
-40
Texture u ..
CL_
G L
G t
Consistence
Fr SSS
,- SP
SS
Structure
Gat
Mineralogy1.
►
l:
HORIZON H DEPTH ..
-
.30
. Z2
Texture groupC
L
Consistence
Fi S
r
er
Structure :
.. 5 l
53
6
Mineralogy;
1
-
HORIZON III DEPTH
ZO r i
_
22-3
Texture groupC
i
Gk5.1
Consistence
-r 5
e- 5S
Structure
S
k-
Mineralo
HORIZON IV DEPTH
d
Texturegroup
Consistence
Structure
Mineralogy.. _ .
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE
O •
-
SITE CLASSIFICATION: EVALUATION B
LONG-TERM ACCEPTANCE RATE: OTHERS) 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 "
ist
VFR -,Very friable' FR -Friable FI - Firm VFI - Very firm EFI - Extremely firm
Wet
R§_: 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)
LIAR - Long-term acceptance rate - gal/day/ft2
Dcau(oi-so)
so
No
■